Gamma Knife Radiosurgery for Metastatic Brain Tumors from Malignant Melanomas: A Japanese Multi-Institutional Cooperative and Retrospective Cohort Study (JLGK1501).

BACKGROUND: The incidences of metastatic brain tumors from malignant melanomas have increased and survival has been prolonged by novel molecular targeted agents and immunotherapy. However, malignant melanomas are uncommon in Asian populations. OBJECTIVES: We retrospectively analyzed treatment efficacy and identified prognostic factors impacting tumor control and survival in Japanese melanoma patients with brain metastases treated with gamma knife radiosurgery (GKRS). METHODS: We retrospectively reviewed the medical records of 177 patients with 1,500 tumors who underwent GKRS for brain metastases from malignant melanomas. This study was conducted by the Japanese Leksell Gamma Knife Society (JLGK1501). RESULTS: Six and 12 months after GKRS, the cumulative incidences of local tumor recurrence were 9.2 and 13.8%. Intratumoral hemorrhage (p < 0.0001) and larger tumor volume (p = 0.001) in GKRS were associated with significantly poorer local control outcomes. The use of immune checkpoint inhibitors before GKRS was significantly associated with symptomatic adverse events (p = 0.037). The median overall survival time after the initial GKRS was 7.3 months. Lower Karnofsky performance status scores (p = 0.016), uncontrolled primary cancer (p < 0.0001), and multiple brain metastases (p = 0.014) significantly influenced unfavorable overall survival outcomes. The cumulative incidences of neurological death 6 and 12 months after GKRS were 9.7 and 17.4%, those of neurological deterioration were 14.2 and 19.6%, and those of new tumor appearance were 34.5 and 40.5%. CONCLUSIONS: The results of the present multicenter study suggest that GKRS is a relatively effective and safe modality for control of tumor progression in Japanese patients with brain metastases from malignant melanomas.

[Multiple cerebral metastasis of a retroperitoneal leiomyosarcoma].

A 61-year-old woman presented with dementia, 7 years after an operation for retroperitoneal leiomyosarcoma. Magnetic resonance imaging (MRI) revealed enhanced masses with perifocal edema in the bilateral frontal regions and a very small mass in the right medial frontal region. The tumors in the bilateral frontal regions were completely removed surgically, and γ-knife radiotherapy was administered for the very small tumor in the right medial frontal region. The histological diagnosis was metastatic leiomyosarcoma. Postoperatively, an MRI showed that the perifocal edemahad decreased, and the symptoms gradually improved. Cerebral metastasis from a retroperitoneal leiomyosarcoma is very uncommon. Ideally, the tumors should be surgically removed because radiotherapy and chemotherapy are apparently ineffective. A combination of complete surgical removal and γ-knife radiotherapy may be effective in prolonging patient survival.

Ruptured aneurysm at the choroidal branch of the posterior inferior cerebellar artery: a case report and review of the literature.

BACKGROUND: The authors present a rare case of a ruptured aneurysm at the choroidal branch of the posterior inferior cerebellar artery (PICA). CASE DESCRIPTION: A 77-year-old female was admitted to our institute because of sudden onset of severe headache and vomiting. Radiologic examination revealed intraventricular hemorrhage caused by rupture of the aneurysm at the choroidal branch of the PICA. The fusiform aneurysm was resected after ligation via a midline suboccipital approach. CONCLUSIONS: The conclusions drawn from this experience and a review of the literature include the following: (1) the aneurysm at the branch of the PICA is frequently associated with anomalies of the vascular structure, particularly in hypoplasty of the contralateral PICA; (2) hemodynamic stress is speculated to be a causative factor of these lesions; (3) cases with hypoplasty of the contralateral PICA have the possibility of developing nonmycotic peripheral aneurysms at the branch of the PICA; (4) these aneurysms should be managed immediately because of the high risk of rebleeding.

Gamma knife surgery for the treatment of spontaneous dural carotid-cavernous fistulas.

Endovascular treatment for a spontaneous dural carotid-cavernous fistula (CCF) is an established treatment, but stereotactic radiosurgery might provide a less-invasive alternative in selected cases. Four women aged 67 to 79 years (mean 72.0 years) with spontaneous dural CCFs presented with chemosis or bruit. Angiography revealed arteriovenous fistulas in the cavernous portion. Three cases were Barrow type D and one was type B converted from type D. Stereotactic gamma knife surgery was performed with a marginal dose of 13-15 Gy and a maximum dose of 26-30 Gy with a volume from 824 to 1755 mm3. The target point of radiosurgery for type D CCFs was the compartment of the cavernous sinus supplied by multiple feeders from the external carotid artery. All patients responded favorably to the treatment, with improvement of symptoms beginning after 1 to 3 months. Angiography confirmed the complete disappearance of the CCFs in all patients. There were no recurrences, and the follow-up period was 14 to 32 months (mean 24 months). No significant side effects were observed. Stereotactic radiosurgery is a useful method to treat CCFs and is indicated for elderly patients, low-flow CCFs, and cases in which endovascular treatment has failed.

Giant fusiform aneurysms in the middle cerebral artery presenting with hemorrhages of different origins. Report of three cases and review of the literature.

Three cases of giant fusiform aneurysms in the middle cerebral artery (MCA) presenting with hemorrhages of different origins are reported, and appropriate literature is reviewed to investigate the characteristics of these lesions. Two patients had suffered a subarachnoid hemorrhage and the other had an intramural hemorrhage (dissection). Pathologically, these aneurysms presented with hemorrhages of different origins; classic rupture type (Case 1), dissection type (Case 2), and atherosclerosis-related thrombosis type (Case 3). Based on surgical and pathological investigations in these three cases and a review of the reported literature, the authors propose that giant fusiform aneurysms in the MCA are characterized by weaknesses in the internal elastic lamina with intimal thickening. Therefore, these lesions have the potential to present with hemorrhage in each of the three types. This finding indicates that there is a strong relationship between the pathological features of giant fusiform aneurysms and their clinical course, and that it is necessary to determine appropriate therapy for giant fusiform aneurysms in the MCA by evaluating cerebral blood flow, even if the lesions are found incidentally.

[A case of pituitary apoplexy with severe consciousness disturbance following mild head trauma].

A rare case of pituitary apoplexy following mild head trauma is reported. A 56-year-old woman was referred to our hospital for loss of consciousness following a traffic accident. Magnetic resonance (MR) imaging showed a large suprasellar tumor containing a low intensity area on the T 1-, T 2-weighted images and fluid-attenuated inversion recovery (FLAIR) image. These findings indicated fresh intratumoral hemorrhage. The tumor extended to the suprasellar region and put pressure on the hypothalamus and brain stem. The tumor, with marked intratumoral hemorrhage, was resected with an emergency right front-temporal craniotomy. And the patient was left severely disabled. The tumor histology was diffuse-type pituitary adenoma. In our case, we suggest that the cause of pituitary apoplexy following head trauma was shearing stress between the intra- and suprasellar part of the easy bleeding tumor, or direct injury by bone structure such as teberculum sellae, dorsum sellae, or anterior clinoid process.

[Gamma knife radiosurgery for malignant melanoma in the paranasal sinuses: case report].

A case of malignant melanoma in the paranasal sinuses, successfully treated with gamma knife stereotactic radiosurgery, is reported. A 90-year-old man with left periorbital swelling was referred to our hospital for gamma knife radiosurgery. He had a 4-month history of left periorbital swelling and ophthalmalgia, but he was treated conservatively due to his age. CT showed a large mass with bone destruction located in the nasal cavity, paranasal sinuses, and orbita. A 15 Gy peripheral dose was administered to the upper portion of the tumor with the gamma knife technique, at the 50% isodose line using a 18 mm collimator (21 shots). Seven months after radiosurgery, his left periorbital swelling was improved markedly, and CT showed a significant reduction in the volume of the tumor. Gamma knife radiosurgery is a feasible treatment for malignant melanoma in the paranasal sinuses. It provides excellent quality of life, less injury to the patient, and fewer side effects than other treatment strategies.

Hammerhead ribozyme against gamma-glutamylcysteine synthetase attenuates resistance to ionizing radiation and cisplatin in human T98G glioblastoma cells.

Glioblastoma cells are highly malignant and show resistance to ionizing radiation, as well as anti-cancer drugs. This resistance to cancer therapy is often associated with a high concentration of glutathione (GSH). In this study, the effect of continuous down-regulation of gamma-glutamylcysteine synthetase (gamma-GCS) expression, a rate-limiting enzyme for GSH synthesis, on resistance to ionizing radiation and cisplatin (CDDP) was studied in T98G human glioblastoma cells. We constructed a hammerhead ribozyme against a gamma-GCS heavy subunit (gamma-GCSh) mRNA and transfected it into T98G cells. (1) The transfection of the ribozyme decreased the concentration of GSH and resulted in G1 cell cycle arrest of T98G cells. (2) The transfection of the ribozyme increased the cytotoxicity of ionizing radiation and CDDP in T98G cells. Thus, hammerhead ribozyme against gamma-GCS is suggested to have potential as a cancer gene therapy to reduce the resistance of malignant cells to ionizing radiation and anti-cancer drugs.

[Giant fusiform aneurysm with dissection in the middle cerebral artery: a case report].

A rare case of a giant fusiform aneurysm with dissection in the middle cerebral artery is reported. A 37-year-old man was referred to our hospital for severe headache and left retrobulbar pain. MRI and angiography showed a giant aneurysm in the temporal branch(M 2) of the left middle cerebral artery. We supposed that dissection had occurred from a giant fusiform aneurysm in the middle cerebral artery judging from presentation, MRI findings, angiography findings, and operative findings. Giant fusiform aneurysms in the middle cerebral artery(MCA) are uncommon cerebral aneurysms. The surgical approach or endovascular treatment to giant fusiform aneurysms in the MCA is technically difficult, so some patients are treated conservativery. However they have a poor natural history that differs from that of typical saccular aneurysms. And they have character of weakness in the internal elastic lamina, and therefore have the potential to dissect. We suggest that appropriate therapy including conservative therapy and surgical techniques is necessary for giant fusiform aneurysms even if they are found incidentally.

[Clinical study of percutaneous endoscopic gastrostomy in neurosurgery].

We investigated the efficacy of percutaneous endoscopic gastrostomy (PEG) in neurosurgery. PEG was applied 94 feeding patients using One-Step Button. The mean age was 70.8 +/- 15.4 years old, and the mean duration between the onset of swallowing disturbance and PEG was 3 months. Minor complication associated with PEG was 8 cases (8.5%), which treated conservatively. Body weight, BMI, and biochemical data were increased one month after PEG, so nutrition was improved. Aspiration pneumonia was improved in 9/18 patients. Fourteen patients got oral intake, and PEG was extracted in 10 patients. PEG was evaluated to be superior to transnasal feeding with regard to simplicity, efficacy, improvement of good nutrition or aspiration pneumonia, and rehabilitation.