Comparative analysis of bevacizumab and LITT for treating radiation necrosis in previously radiated CNS neoplasms: a systematic review and meta-analysis

PURPOSE

Radiation necrosis (RN) is a local inflammatory reaction that arises in response to radiation injury and may cause significant morbidity. This study aims to evaluate and compare the efficacy of bevacizumab and laser interstitial thermal therapy (LITT) in treating RN in patients with previously radiated central nervous system (CNS) neoplasms.

METHODS

PubMed, Cochrane, Scopus, and EMBASE databases were screened. Studies of patients with radiation necrosis from primary or secondary brain tumors were included. Indirect meta-analysis with random-effect modeling was performed to compare clinical and radiological outcomes.

RESULTS

Twenty-four studies were included with 210 patients in the bevacizumab group and 337 patients in the LITT group. Bevacizumab demonstrated symptomatic improvement/stability in 87.7% of cases, radiological improvement/stability in 86.2%, and steroid wean-off in 45%. LITT exhibited symptomatic improvement/stability in 71.2%, radiological improvement/stability in 64.7%, and steroid wean-off in 62.4%. Comparative analysis revealed statistically significant differences favoring bevacizumab in symptomatic improvement/stability (p = 0.02), while no significant differences were observed in radiological improvement/stability (p = 0.27) or steroid wean-off (p = 0.90). The rates of adverse reactions were 11.2% for bevacizumab and 14.9% for LITT (p = 0.66), with the majority being grade 2 or lower (72.2% for bevacizumab and 62.5% for LITT).

CONCLUSION

Both bevacizumab and LITT exhibited favorable clinical and radiological outcomes in managing RN. Bevacizumab was found to be associated with better symptomatic control compared to LITT. Patient-, diagnosis- and lesion-related factors should be considered when choosing the ideal treatment modality for RN to enhance overall patient outcomes.

Widening the Operative Corridor-Evaluating the Transcortical Approach to Giant Falcine Meningiomas

BACKGROUND

Giant falcine meningiomas are surgically complex as they are deep in location, concealed by normal brain parenchyma, in close proximity to various neurovascular structures, and frequently involve the falx bilaterally. Although classically accessed using a bifrontal craniotomy and interhemispheric approach, little data exist on alternative operative corridors for these challenging tumors. We evaluated perioperative and long-term outcomes in patients undergoing transcortical resection of giant bilateral falcine meningiomas.

METHODS

From 2013 to 2022, fourteen patients with giant bilateral falcine meningiomas treated via a transcortical approach at our institution were identified. Perioperative and long-term outcomes were evaluated to determine predictors of adverse events. Corticectomy depth was also analyzed to determine if it correlated with increased postoperative seizure rates.

RESULTS

57.1% of cases were WHO grade 2 meningiomas. Average tumor volume was 77.8 ± 46.5 cm3 and near/gross total resection was achieved in 78.6% of patients. No patient developed a venous infarct or had seizures in the 6 months after surgery. Average corticectomy depth was 0.83 ± 0.71 cm and increasing corticectomy depth did not correlate with higher risk of postoperative seizures (P = 0.44). Increasing extent of tumor resection correlated with lower tumor grade (P = 0.011) and only 1 patient required repeat resection during a median follow-period of 24.9 months.

CONCLUSIONS

The transcortical approach is a safe alternative corridor for accessing giant, falcine meningiomas, and postoperative seizures were not found to correlate with increasing corticectomy depth. Further prospective studies are necessary to determine the best approach to these surgically complex lesions.

Trends in medical device company payments in neurosurgery: a nationwide, multidatabase, geospatial analysis

OBJECTIVE

Industry partnerships help advance the field of neurosurgery. Given the nature of the field and its close relationship with innovation, neurosurgeons frequently partner with the medical device industry to advance technology and improve outcomes. However, this can create important ethical concerns for patients. In this paper, the authors sought to comprehensively study how physician payments from medical device companies have changed and what geographic parameters influence the trends observed over the years.

METHODS

The authors queried and merged several large databases, including Medicare and Medicaid provider usage data and databases from the Open Payments Program, National Plan and Provider Enumeration System, and US Census Bureau. Geospatial analysis was performed using Moran's I and II clustering. Univariate and multivariable analyses were performed using the Mann-Whitney U-test and geospatially weighted multivariable regression for hot spot and cold spot membership.

RESULTS

Data for 952 counties across the continental United States were analyzed. Ninety-seven counties constituted geographic hot spots. These hot spots were primarily concentrated in Florida, the New York-Pennsylvania region, central Colorado, and southwestern United States. Independent predictors of hot spot membership included greater unemployment rates, the percentage of White patients, the presence of mobile homes, and the percentage of county Hispanic and Black populations. Company-based differences were examined. The vast majority of Medtronic's payments were in the form of royalties and licensing (86.6%). Royalties and licensing accounted for the majority of payments for DePuy (69.4%), Globus Medical (62%), and NuVasive (77.1%). In contrast, other companies, such as Boston Scientific, opted to pay physicians in the form of ownership and investment interests (42.1%). The impact of the COVID-19 pandemic was also assessed. During the onset of the pandemic in 2020, physician payments fell or remained the same across all regions with the exception of the South Atlantic region. However, it was observed that nearly all regions rebounded, with stark elevations in physician payments immediately in 2021.

CONCLUSIONS

This analysis demonstrates that there are national hot spots and cold spots of physician payments, and offers some social, economic, and company-dependent predictors that may influence the magnitude of payments. Further analysis is needed to better understand this clinical-commercial partnership in healthcare, specifically within neurosurgical practice.

Sex and gender differences in lower limb chronic exertional compartment syndrome: a systematic review

OBJECTIVES

Chronic exertional compartment syndrome (CECS) is a cause of exertional leg pain and has been reported in varying frequencies in males and females. Currently, it is unclear whether there are significant sex and gender differences in lower-limb CECS. Delineating sex and gender differences is vital in determining the causes of CECS and best treatments. This systematic review aimed to determine the sex/gender distribution of CECS and to assess for sex and gender differences in CECS diagnosis and outcomes.

METHODS

PubMed (Medline), Cochrane Library, and EMBASE databases were searched for studies that were published from January 2000-March 2022 and reported lower-limb CECS data in males and/or females. Data on CECS diagnosis (intracompartmental pressures) and outcomes (e.g. post-surgical return-to-sport, need for re-operation) with sex/gender breakdowns were extracted. The sex/gender distribution of CECS and prevalence of CECS by sex/gender were calculated.

RESULTS

Forty-one studies were included in the systematic review; there were 27 retrospective reviews, 8 prospective studies, and 6 retrospective studies with prospective follow-ups. Thirty studies involved surgical populations. Sex/gender distribution of CECS was calculated using data from 24 studies; 51% were female. Prevalence of CECS was available in five studies and ranged widely for males (54%-73%) and females (43%-65%). Intracompartmental pressure data varied by sex/gender. Male athletes were more likely than female athletes to return to sport following surgery for CECS, but variations in all other post-surgical outcomes were observed between sexes and genders in the general population.

CONCLUSION

Females represented 51% of the patients who were diagnosed with CECS among studies. Most CECS diagnosis and outcomes data varied by sex/gender, except for post-surgical outcomes data in athletes, which demonstrated that males had higher rates of return to sport than females. Future studies are needed to examine factors contributing to sex and gender differences in CECS diagnosis and outcomes.

Intrathecal chemotherapy for leptomeningeal disease in high-grade gliomas: a systematic review

BACKGROUND

Leptomeningeal disease (LMD) secondary to high grade glioma (HGG), such as glioblastoma (GBM), are characterized by the spread of tumor cells to the leptomeninges which further complicates treatment approaches. Intrathecal (IT) chemotherapy has surfaced as a potential strategy to bypass the blood-brain barrier and address the challenges posed by disseminated disease. Here, we present a review of the safety and efficacy of IT chemotherapy in the treatment of LMD secondary to HGG.

METHODS

A systematic review following PRISMA guidelines was conducted searching PubMed and Embase from January 1995 to September 2022 using specified terms related to IT chemotherapy for LMD. Included articles involved patients diagnosed with LMD from HGG, treated with intrathecal chemotherapy, and provided survival data. Data, including demographics, tumor characteristics, treatment, and survival information, were collected and independently extracted.

RESULTS

A total of 68 patients across 10 clinical studies were diagnosed with LMD from HGG and included in the review. Among these patients, the average age at diagnosis was 44.2 years. GBM was the most common tumor type (n = 58, 85.3%). A majority of the patients presented with recurrent disease (n = 29, 60.4%). The review encompassed various IT chemotherapy regimens, including mafosfamide, thio-TEPA, 5-fluoro-2'-deoxyuridine (FdUrd), methotrexate (MTX), and cytarabine; however, dosages and frequencies were inconsistently reported. The mean progression-free survival (PFS) and overall survival (OS) for this cohort were 7.5 months and 11.7 months, respectively. Common side effects of IT chemotherapy included headaches, nausea, and vomiting, with more severe complications such as myelotoxicity, disseminated intravascular coagulopathy, meningitis, and gastrointestinal toxicity reported in some cases.

CONCLUSION

LMD continues to be an uncommon complication associated with HGG with a poor prognosis. This article provides an overview of the presently available literature on IT chemotherapy for LMD secondary to HGG, and their respective treatment protocols with overall survival attributes. Additional research is warranted to ascertain how to maximize the potential efficacy of IT chemotherapy as a treatment option.

Surgical Outcomes of Awake Craniotomy for Treatment of Arteriovenous Malformations in Eloquent Cortex: A Systematic Review

OBJECTIVE

Arteriovenous malformations (AVM) located in eloquent brain regions are historically associated with a poor prognosis. Awake craniotomy (AC) with the adjunct of brain mapping has the potential of identifying non-eloquent gyri to maximize resection, thereby theoretically decreasing the risk of neurologic deficits. With limited evidence regarding the efficacy of AC in treatment of eloquent AVMs, this review aims to investigate its surgical outcomes.

METHODS

A systematic search in the PubMed database was performed to identify all relevant studies up to February 2022.

RESULTS

13 studies were extracted for quantitative analysis, yielding a total of 46 patients. The mean age was 34.1 years, and most patients were female (54.8%). Seizures were the most frequently reported presenting symptom (41%, 19/46 cases). Spetzler-Martin Grade III was the most prevalent (45.9%, 17 cases) with a mean nidus size of 32.6 mm. Seventy-four percent of AVMs were located on the left-side, with the frontal lobe being the most common location (30%, 14/46 cases). The most common eloquent regions were language (47.8%, 22/46 cases), motor (17.4%, 8/46 cases), and language + motor cortices (13.1%, 6/46 cases). Complete resection of AVM was achieved in 41 patients (89%). Intraoperative complications occurred in 14/46 cases (30.4%) with transient postoperative neurologic deficits in 14 patients (30.4%).

CONCLUSION

AC may enable precise microsurgical excision of eloquent AVMs with preservation of critical brain functions. Risk factors for poor outcomes include eloquent AVMs located in the language + motor regions and the occurrence of intraoperative complications such as seizures/hemorrhage.

Social Media and the Orthopaedic Surgery Residency Application Process

Introduction: Social media use in the residency application process has been on the rise, yet applicant and program director (PD) perspectives in orthopaedic residency have not been explored in depth. Our objective is to evaluate perspectives of orthopaedic residency applicants and PDs on social media usage and its impact on the residency application process.

Methods: Cross-sectional survey study conducted in 2021 with two related, anonymous surveys sent to residency applicants and PDs. One hundred thirteen of 562 (20.1%) applicants to our institution and 29 of 148 (19.6%) PDs listed on the Accreditation Council for Graduate Medical Education (ACGME) website responded to our survey and were included in the analysis.

Results: Applicants reported learning about residency programs through Instagram (69.2%), the program website (58.9%), and Doximity (29.9%). Thirty-four percent of applicants reported social media influencing their rank list, with non-training-related posts being the most impactful. PDs reported that 97% of their programs have an official web page, 41% have an active Instagram site, 27% have a Twitter account but none regularly update Doximity. Just over 48% of PDs reported institutional support for online content creation. Financial investment varied, with 35% reporting no spending, and 24% spending over $2501. In response to coronavirus disease 2019 (COVID-19) restrictions, 79% of PDs reported generating increased social media content.

Discussion: Social media provides a low-cost but far-reaching opportunity for PDs to recruit residents and highlight their respective programs. Social media content should display the culture and lifestyle of the program, with consistency in content creation. PDs should also ensure accuracy on external sites such as Doximity.