Management of non-benign meningiomas with Gamma Knife radiosurgery.

OBJECTIVE: Results of Gamma Knife radiosurgery (GKS) were retrospectively evaluated in 16 patients with histologically confirmed atypical and anaplastic intracranial meningiomas. MATERIALS AND METHODS: There were nine men and seven women (mean age 61.0 years). Atypical meningiomas were diagnosed in nine cases and anaplastic meningiomas in seven. In nine patients there was malignant transformation of a tumor that had initially proved to be benign. In total, 21 radiosurgical procedures were performed. The mean tumor volume at the time of GKS was 7.1 cm3. The mean marginal and maximum irradiation doses were 18.8 and 37.0 Gy, respectively. The mean length of follow-up after treatment was 37.1 months. FINDINGS: Of 21 radiosurgical procedures, 6 (29 %) led to stabilization of tumor growth during the mean follow-up of 40.5 months. It was significantly associated with small lesion volume (P = 0.02), and greater marginal (P = 0.04) and maximum (P = 0.02) irradiation doses. Seven patients underwent eight surgical resections of a progressing tumor during the mean period of 26.1 months after irradiation. Five patients (31 %) died because of tumor progression within the average time period of 16.8 months after GKS. Overall, at the time of the last follow-up just two patients (13 %) had no evidence of tumor regrowth, and only three patients (19 %) maintained good activities of daily living during 12, 59, and 69 months, respectively, after radiosurgery. CONCLUSION: GKS has limited efficacy in cases of non-benign meningioma. Better tumor control rates can be attained for small neoplasms treated with greater marginal and maximum irradiation doses.

[Initial division of the left renal vein before dissection of left renal vein occluded by intracaval tumor thrombus].

Between November 2008 and March 2010, we performed initial division of the left renal vein occluded by the tumor thrombus in six cases of left renal cancer at Toranomon Hospital. The left renal vein was completely occluded by the tumor thrombus in all cases. In order to ligate the left renal artery first behind the dilated left renal vein, we must dissect the left kidney with arterial blood flow. Massive bleeding from the numerous engorged collateral veins around the left kidney is inevitable. Furthermore, access to the left renal artery is difficult because of the large tumor. We therefore initially divided the left renal vein without arterial blood flow followed by division of the left renal artery. After nephrectomy by dissecting the tumor without blood flow we extirpated the intracaval tumor thrombus. The median time of the operation was 7 hours 35 minutes and the median amount of blood loss was 2,869 ml. The tumor stage was pT3b in four cases and pT3c in two cases. No complications were observed during and after surgery except for one case of lymphocele and another case of chylous ascites. The initial division of the left renal vein is considered to be a useful surgical approach in left renal cancer with occluded left renal vein, especially when the tumor is large.

[The initial division of left renal vein in left renal cancer with intracaval tumor thrombus: a case report].

A 30-year-old female was admitted to our hospital with a 3-month history of general fatigue and one month history of left flank mass. Computed tomography revealed a huge left renal tumor (20 × 13 × 10 cm) with intracaval tumor thrombus. The tumor thrombus extended into the right atrium. The left renal vein (lt-RV) was expanded 3.5 cm in diameter by the tumor thrombus. The tumor was surrounded by a tortuous dilated capsular vein. The strategic issue was how to ligate the left renal artery (lt-RA) behind the expanded lt-RV. We first divided the lt-RV occluded by the tumor thrombus using a Linear Cutter® and then divided the lt-RA before the dissection of the tumor to avoid excessive bleeding. Even transarterial embolization of lt-RA were to be performed,the tumor was too large to dissect without division of lt-RV and lt RA. After the left kidney was removed,the lower half of the tumor thrombus was excised,clamping the inferior vena cava,three right renal arteries,two right renal veins,and the lumber vein. Finally,we removed the upper half of the tumor thrombus extending to the right atrium through atriotomy and cavotomy under an extracorporeal cardiovascular bypass. Operation time was 9 h 22 m,and total blood loss was 1670 ml. Convalescence was uneventful except for abdominal lymphocele.

A template for forward planning in prostate cancer treatment: conformal irradiation with segmental intensity-modulation.

BACKGROUND AND PURPOSE: The use of intensity-modulated radiotherapy (IMRT) has proven to be effective in radiation therapy of the prostate, but difficulties in quality assurance (QA) and prolonged planning time are considered problems. We proposed a template for prostate irradiation using conventional treatment fields. MATERIALS AND METHODS: To establish a general treatment method, we used computed tomography scan studies of 50 male patients with various diseases as anatomic references for planning. Ten ports were used for irradiation. Each port was set to the same weight and at the same angle. RESULTS: The plans for all cases were generated easily, and dose distributions showed uniform properties. Dose volume histogram (DVHs) of all the plans gave an approximated distribution. The results showed hardly any influenced due to body shape or the prostate size. The average dose in the planning target volume (PTV) was very close to the prescribed dose (75Gy), and the average normal tissue complication probability (NTCP) of the rectum was 1.61. CONCLUSIONS: Although direct comparison with IMRT is difficult, the treatment plan obtained using this method is not inferior to those obtained using conventional IMRT plans. Moreover, it is useful as a standard in the comparison of various treatment plans.

Agraphia with abnormal writing stroke sequences due to cerebral infarction.

A 65-year-old, right-handed man presented with speech and gait disturbances. He was alert and cooperative, showing mild right hemiparesis and sensory disturbance. Spontaneous speech was fluent; object naming, word fluency and reading were fully preserved. Sentence repetition and verbal comprehension were mildly impaired. Writing was slow, hesitant and difficult for both spontaneous writing and dictation. Copying was better, although he had some difficulty in copying letters and also complex figures. Sequences of strokes in forming written characters were abnormal; strokes were formed by piecing together several fragments. Computed tomography and magnetic resonance imaging showed a subcortical infarct in the left frontoparietal region. Characteristics of agraphia resembled 'apractic agraphia' and agraphia may have resulted largely from loss or unavailability of the memory of motor patterns necessary for writing letters.

Relationships between event-related potentials and neuropsychological tests in neurologically healthy adults.

The aim of this study was to investigate the relationship between conventional neuropsychological tests and an event-related potential (P300). Subjects were 118 neurologically normal healthy adults 18-74 years old with no history of neurological, neurosurgical, or psychiatric disorders. We administered a neuropsychological test battery and recorded auditory P300 in all subjects. A significant correlation was seen between P300 latency and age, but not between amplitude and age. While significant negative correlations were apparent between some neuropsychological tests and age and P300 latency, stepwise regression analysis to assess the significance of each factor determined that age alone correlated with P300 latency. We therefore concluded that P300 measurements cannot be replaced by neuropsychological tests; rather, brain function should be evaluated by both methods.