Brain metastases in cancer patients attending a Gamma Knife Center: A study from a single institute in Iran.

BACKGROUND: This study was aimed to explore data on brain metastases in cancer patients attending the Iranian Gamma Knife Center. METERIALS AND METHODS: This was a retrospective study. In all 5216 case records of patients who referred to the Iranian Gamma Knife Center for treatment of brain tumors during year 2003-2011 were reviewed. Data were explored to identify patients who developed brain metastases due to cancer and assessed the information as applied to cancer patients including survival analysis. RESULTS: Two hundred and twenty patients were identified as having brain metastases due to cancer. The mean age of patients was 54.0 (standard deviation [SD] =12.7) years. Patients were followed for an average of 7 months after treatment with gamma-knife. The median survival time for different the Graded Prognostic Assessment (GPA) was: GPA: 0-1, 4.0 ± 0.4 months; GPA: 1.5-2.5, 6.0 ± 0.7 months; GPA: 3, 9.0 ± 0.9 months; and GPA: 3.5-4.0, 12.0 ± 1.8 months and the overall median survival was 7.0 (SD = 0.6) months. CONCLUSION: The findings suggest that many cancer patients in Iran might develop brain metastasis. Although, this is not a very high incidence compared with the existing statistics from other countries, there is an urgent need to explore the issue further.

Effects of Copper Reduction on Angiogenesis-Related Factors in Recurrent Glioblastoma Cases

Purposeː To evaluate the therapeutic effects of copper reduction on angiogenesis-related factors in patients with glioblastoma multiforme treated by gamma knife radiosurgery. Materials and Methodsː In the present block randomized, placebo-controlled trial, fifty eligible patients with a diagnosis of glioblastoma multiforme who were candidates for gamma knife radiosurgery were randomly assigned into two groups to receive daily either 1gr penicillamine and a low copper diet or placebo for three months. The intervention started on the same day as gamma knife radiosurgery. Serum interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), vascular endothelial growth factor (VEGF) and copper levels were measured at baseline and after the intervention. The serum copper level was used as the final index of compliance with the diet. In order to control probable side effects of intervention, laboratory tests were conducted at the beginning, middle and end of the study. Resultsː The patients had a mean age and Karnofsky Performance Scale of 43.7 years and 75 respectively. Mean serum copper levels were significantly reduced in intervention group. Mean survival time was 18.5 months in intervention group vs. 14.9 in placebo group. VEGF and IL-6 levels in the intervention group were also significantly reduced compared to the placebo group and TNF-α increased less. Conclusionsː It seems that reducing the level of copper in the diet and dosing with penicillamine leads to decline of angiogenesis-related factors such as VEGF, IL-6 and TNF-α. Approaches targeting angiogenesis may improve survival and can be used as a future therapeutic strategy.

Cavernomas: Outcomes after gamma-knife radiosurgery in Iran.

BACKGROUND: Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after gamma-knife surgery (GKS) for these patients. MATERIALS AND METHODS: A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received ≤13 Gy; and those who received >13 Gy. The demographic and clinical characteristics of patients including age, gender, and hemorrhage rates were extracted from care records. RESULTS: The median age was 32.5 years (ranging from 15 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm(3) (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow-up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1% and 1.9% thereafter. There was no mortality due to GKS, and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy. CONCLUSION: The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of cavernous malformations.

Repeated transsphenoidal surgery or gamma knife radiosurgery in recurrent cushing disease after transsphenoidal surgery.

BACKGROUND: This study compared Gamma knife radiosurgery (GKRS) and repeated transsphenoidal adenomectomy (TSA) to find the best approach for recurrence of Cushing disease (CD) after unsuccessful first TSA. MATERIAL AND METHODS: Fifty-two patients with relapse of CD after TSA were enrolled and randomly underwent a second surgery or GKRS as the next therapeutic approach. They were followed for a mean period of 3.05 ± 0.8 years by physical examination and hormone measurement as well as magnetic resonance imaging. RESULTS: No significant difference was observed in sex ratio, mean age, adenoma type, follow-up duration, and initial hormone level between the two groups. No significant relationship was found between preoperative 24-hour free urine cortisol and disease-free months or tumor volume among both groups. Our statistical analysis showed higher recurrence-free interval in the GKRS group compared with TSA group. CONCLUSION: With longer recurrence-free interval, GKRS could be considered a good treatment alternative to repeated TSA in recurrent CD.

Corpus callosotomy with gamma knife radiosurgery for a case of intractable generalised epilepsy.

Gamma knife radiosurgery is a minimally invasive procedure which can be used for patients with intractable epilepsies as an alternative for surgical corpus callosotomy. We report a 13-year-old boy with intractable epilepsy who underwent radiosurgical callosotomy. The patient demonstrated significant clinical improvement after gamma knife radiosurgery and was free of seizures 10 months after the procedure. However, He developed four short focal seizures with clonic movements during the 20 months post radiosurgery. Corpus callosotomy decreased epileptiform discharges in both hemispheres, indicating a role for the callosal neurons to facilitate an asymmetric epileptogenic susceptible state within the two hemispheres such that bisynchronous and bisymmetrical epileptiform discharges develop. Our result demonstrates that this novel therapeutic approach is a safe and effective option for the treatment of intractable generalised epilepsies.

Gamma knife radiosurgery in patients with trigeminal neuralgia: quality of life, outcomes, and complications.

OBJECTIVE: to assess the outcomes, complications, and alteration in quality of life (QOL) in patients with trigeminal neuralgia who were treated with gamma knife radiosurgery (GKRS) in a prospective observational study. METHODS AND MATERIALS: between June 2006 and May 2007, 30 patients of medically refractory trigeminal neuralgia were included in our study and treated with GKRS at Iran Gamma Knife Centre (IGKC), Tehran, Iran. A median maximum prescription dose of 90Gy (range: 85-95) was delivered to the trigeminal nerve root entry zone. All involved patients completed QOL questionnaire SF-36 before GKRS and 9-12 months after it. All data from questionnaires and the basic characteristics of the radiosurgery and patients were analyzed using descriptive statistics, paired T-test, Fisher's exact test, bivariate correlation, and independent sample T-test. RESULTS: In all SF-36 domains significant changes before and after GKRS were noticed except physical function (PF) and role limitation due to physical problem (RP). Bodily pain after GKRS was 100 (excellent result) in 12 (40%) of study participants, 90-99 (good result) in 3 (10%), 50-89 (fair result) in 10 (33%) and less than 50 (poor result) in five (17%). Four cases (13%) faced to facial numbness. No other complications were noticed. CONCLUSIONS: GKRS positively changes the several aspect of QOL especially those related to pain relief and mental health component of QOL. The rate of diminishing pain in our study is comparable with other series. The GKRS complication is limited in both variety and number.

Radiosurgery for glomus jugulare tumors: experience treating 16 patients in Iran.

OBJECT: Glomus jugulare tumors (GJT) have traditionally been treated by surgery or fractionated external-beam radiotherapy. The aim of this retrospective study was to determine the tumor control rate, clinical outcome, and short-term complications of stereotactic radiosurgery in subsets of patients who are poor candidates for these procedures, based on age, medical problems, tumor size, or prior treatment failure. METHODS: The Leksell Gamma Knife was used to treat 16 patients harboring symptomatic, residual, recurrent, or unresectable GJTs. The age of the patients ranged from 12 to 77 years (median 46.5 years). Gamma Knife surgery (GKS) was performed as primary treatment in five patients (31.3%). Microsurgery preceded radiosurgery in 10 patients (62.5%) and fractionated radiotherapy in three patients (18.8%). The median tumor volume was 9.8 cm3 (range 1.7-20.6 cm3). The median marginal dose applied to a mean isodose volume of 50% (range 37-70%) was 18 Gy (range 14-20 Gy). Neurological follow-up examinations revealed improved clinical status in 10 patients (62.5%), a stable neurological status in six (37.5%), and no complications. After radiosurgery, follow-up imaging was conducted in 14 patients; the median interval from GKS to the last follow up was 18.5 months (range 4-28 months). Tumor size had decreased in six patients (42.9%), and the volume remained unchanged in the remaining eight (57.1%). None of the tumors increased in volume during the observation period. CONCLUSIONS: According to the authors' experience, GKS represents a useful therapeutic option to control symptoms and may be safely conducted in patients with primary or recurrent GJTs with no death and no acute morbidity. Because of the tumor's naturally slow growth rate, however, long-term follow-up data are needed to establish a cure rate after radiosurgery.