Meningioma Presenting With Intratumoral Hemorrhage on Active Surveillance.

Meningiomas are relatively common primary adult brain tumors. They are slow-growing, highly vascular, and graded according to histology, phenotypic and genotypic features. We present a case of a 66-year-old male with a history of tongue squamous cell carcinoma, which presented multiple risk factors for cardiovascular and thromboembolic events. A brain lesion was initially detected on a computed tomography (CT) scan and later characterized by magnetic resonance imaging (MRI). The multidisciplinary team decided to maintain surveillance due to the lack of associated symptoms. Upon expansion in size and acute intralesional hemorrhage seen on follow-up imaging, the patient was submitted to surgical excision. The histopathological testing determined it to be an atypical meningioma. Two months later, the patient received stereotactic radiotherapy, and a post-surgical MRI showed no evidence of tumor recurrence. This case report describes a rare occurrence of intratumoral hemorrhage in a meningioma during surveillance, highlighting the importance of vigilant monitoring and consideration of potential risk factors for hemorrhagic events.

History and Evolution of Radiosurgery in India: Strength to Strength.

Stereotactic radiosurgery (SRS) has been well received by the neurosurgical community since its introduction in India. Knowledgeable radiosurgeons and visionary neurosurgeons have contributed to its success. At present, we have five functional and busy gamma knife centers, one proton radiosurgery center, and seven CyberKnife centers in India. However, there is a need for more such centers and formal training facilities, especially in the unorganized private sector. Radiosurgery has expanded its horizon from its initial indications of vascular and benign disorders to functional ailments and metastasis. Here, we take a look at the seminal points in its development in India along with the centers of excellence that contributed to the same. While we have tried to cover all the facets of its development, it is natural to miss some undocumented events not available in public domain. Nonetheless, the future of radiosurgery seems promising in India with the assurance of minimally invasive, safe, and effective treatment delivery.

Gamma Ray Radiosurgery for Trigeminal Neuralgia: Targeting Proximal or Distal to the Dorsal Root Entry Zone.

Introduction Stereotactic radiosurgery for trigeminal neuralgia (TN) has gained interest among patients who are not suitable for surgical procedures. Although two target zones are more recognized - dorsal root entry zone (DREZ) and retrogasserian zone (RGZ) - the optimal targeting technique remains controversial in terms of clinical outcomes and rates of complications. Therefore, various modifications to the radiosurgical technique for TN have been made. Objective This study aimed to determine the differences in shoot location (i.e., RGZ vs. DREZ) regarding effectiveness and adverse effects in patients with medically refractory TN. Additionally, we evaluated the effect of the integral dose (ID) on treatment outcomes and complications. Methods We present a retrospective cohort study of 49 patients with primary, drug-resistant TN treated with gamma knife radiosurgery targeting the distal and proximal parts of the nerve regarding the DREZ with a prescription dose of 90 Gy (80 to 96 Gy). A subset of these patients (n=38) where the ID could be measured to the nerve was correlated to treatment outcomes and complications. Results The median follow-up time was 36 months for RGZ and 51 months for DREZ targets. Neurovascular conflict was identified in 87.5% of the RGZ group and 88.2% of the DREZ group. Using the Barrow Neurological Institute (BNI) pain score, 26 (81.3%) RGZ and 12 (70.6%) DREZ patients were successfully treated (BNI I-IIIb; p=0.02). Seven (21.9%) RGZ and eight (47.1%) DREZ patients reported complete pain relief without medication (BNI I). Time response was 22.3 days for RGZ and 34.1 days for DREZ (p=0.277). There were 10 (31.3%) patients in the RGZ group with associated complications versus six (35.3%) patients in the DREZ group (χ2=0.0826, degree of freedom=1, p=0.773). Treatment outcomes using higher ID were better in the RGZ than DREZ (81.8% vs. 57.1, respectively), and a significant association was found between a higher ID delivered to the nerve and the development of complications (p=0.02). Conclusion Based on the obtained results, the RGZ was a more effective targeting area with better treatment outcomes without significant differences in complication rates than DREZ. A higher ID at the RGZ than DREZ had a greater therapeutical effect. Further investigation regarding the optimal target area along the ID delivered and clinical outcomes are required.

Self-Shielding for the ZAP-X®: Revised Characterization and Evaluation.

The ZAP-X® is a newly designed, self-contained, and first-of-its-kind self-shielded therapeutic radiation therapy device dedicated to brain and head and neck stereotactic radiosurgery (SRS). By using an S-band linear accelerator (linac) and employing integrated minimal but sufficient shielding, the ZAP-X does not typically require a radiation bunker. At the same time, the self-shielded features of the ZAP-X are designed for more consistency of radiation protection, reducing the risk to radiation workers and others potentially exposed from a poorly designed or constructed radiotherapy vault. This study postulates that a radiosurgical system can be self-shielded, such that it produces radiation exposure levels deemed safe to the public while operating under a full clinical workload. The goal of self-shielding is achieved under all but the most exceptional clinical conditions. This work is intended to serve as guidance for the radiation safety evaluations of future ZAP-X treatment operations, following local or regional applicable regulatory requirements, and utilizing the unique provision of all or most of the required shielding material as an integral part of the device.

Local Therapy Indications in the Management of Patients with Oligometastatic Non-Small Cell Lung Cancer.

Advances in surgical, radiation, and interventional radiology therapies carry a reduction in morbidity associated with therapy. Aggressive management of patients with oligometastatic non-small cell lung cancer offers the potential for improved disease-free survival and quality of life compared with traditional systemic therapy alone.

Targeting Accuracy of Image-Guided Radiosurgery for Intracranial Lesions: A Comparison Across Multiple Linear Accelerator Platforms.

PURPOSE: To evaluate the overall positioning accuracy of image-guided intracranial radiosurgery across multiple linear accelerator platforms. METHODS: A computed tomography scan with a slice thickness of 1.0 mm was acquired of an anthropomorphic head phantom in a BrainLAB U-frame mask. The phantom was embedded with three 5-mm diameter tungsten ball bearings, simulating a central, a left, and an anterior cranial lesion. The ball bearings were positioned to radiation isocenter under ExacTrac X-ray or cone-beam computed tomography image guidance on 3 Linacs: (1) ExacTrac X-ray localization on a Novalis Tx; (2) cone-beam computed tomography localization on the Novalis Tx; (3) cone-beam computed tomography localization on a TrueBeam; and (4) cone-beam computed tomography localization on an Edge. Each ball bearing was positioned 5 times to the radiation isocenter with different initial setup error following the 4 image guidance procedures on the 3 Linacs, and the mean (µ) and one standard deviation (σ) of the residual error were compared. RESULTS: Averaged overall 3 ball bearing locations, the vector length of the residual setup error in mm (µ ± σ) was 0.6 ± 0.2, 1.0 ± 0.5, 0.2 ± 0.1, and 0.3 ± 0.1 on ExacTrac X-ray localization on a Novalis Tx, cone-beam computed tomography localization on the Novalis Tx, cone-beam computed tomography localization on a TrueBeam, and cone-beam computed tomography localization on an Edge, with their range in mm being 0.4 to 1.1, 0.4 to 1.9, 0.1 to 0.5, and 0.2 to 0.6, respectively. The congruence between imaging and radiation isocenters in mm was 0.6 ± 0.1, 0.7 ± 0.1, 0.3 ± 0.1, and 0.2 ± 0.1, for the 4 systems, respectively. CONCLUSIONS: Targeting accuracy comparable to frame-based stereotactic radiosurgery can be achieved with image-guided intracranial stereotactic radiosurgery treatment.