Patterns of Radiotherapy Utilization for Lung Cancer Patients with Brain Metastases: A Population-based Analysis.

INTRODUCTION: Brain metastases occur in 15%-20% of lung cancer patients. Recently, studies have suggested that whole-brain radiotherapy (WBRT) may not prolong survival for a subset of patients, and is associated with significant side-effects. Furthermore, it is hypothesized that radiotherapy is often given near the end-of-life when the potential for benefit is minimal. Therefore, this study investigates how frequently radiotherapy for brain metastases is given near the end-of-life in a population-based cohort. MATERIALS AND METHODS: All lung cancer patients who received radiotherapy in British Columbia for brain metastases in 2014-2015 were identified. Patient and treatment characteristics were collected and analyzed to assess associations with death within 90 days of first radiation treatment. RESULTS: In total, 740 patients were identified, with a total of 826 courses of brain radiation. The 90-day mortality rate was 40% (n=330). Multivariable analysis demonstrated higher odds for age (odds ratio (OR) = 1.04, 95% confidence interval (CI) 1.02-1.05), Eastern Cooperative Oncology Group (ECOG) performance score of 2 or higher (OR = 1.59, 95% CI 1.09-2.31) and squamous cell carcinoma (OR = 2.10, 95% CI 1.13-3.90) and lower odds for initial systemic therapy (OR = 0.48, 95% CI 0.34-0.68), more than five fractions of radiotherapy (OR = 0.25, 95% CI 0.16-0.39) and stereotactic radiation (OR = 0.29, 95% CI 0.13-0.65). CONCLUSION: In our population-based study, WBRT is given in 86% of radiotherapy courses for brain metastases from lung cancer. Of these patients, 40% received treatment near the end-of-life. We identified several factors associated with shortened survival. Using these factors and already established prognostic tools, WBRT utilization should be decreased in the future, improving individualized treatment for patients with brain metastases from lung cancer.

Palliative thoracic radiotherapy near the end of life in lung cancer: A population-based analysis.

OBJECTIVES: Palliative thoracic radiotherapy (RT) can improve quality of life for patients with advanced lung cancer, but treatment can be associated with acute toxicity and symptomatic relief may take several weeks. The optimal fractionation schedule is not known. Delivery of RT near the end of life (EOL) is an emerging indicator of poor quality care. The aim of this study was to determine utilization of palliative thoracic RT in the last 4 weeks of life, and factors associated with its use, in patients with incurable lung cancer in a population-based healthcare system. MATERIALS AND METHODS: All patients with lung cancer in British Columbia treated with palliative thoracic RT in 2014 and 2015 were identified. Associations between starting a course of palliative thoracic RT within 4 weeks of death and patient/treatment characteristics were assessed using univariate and multivariate logistic regression analysis. RESULTS: 1676 courses of palliative thoracic RT were delivered to 1584 lung cancer patients. Median survival was 20 weeks. 12% of palliative thoracic RT courses were delivered in the last 4 weeks of life, with short fractionation schedules and simple RT planning techniques used more frequently near EOL. Of RT courses delivered in the last 4 weeks of life 89% were courses of 1 - 5 fractions, 75% were completed as prescribed and 94% involved simple 1-2 field RT techniques. Receipt of RT in the last 4 weeks of life was associated with male gender, younger age, poor performance status, metastatic disease, small cell carcinoma histology and no prior chemotherapy. CONCLUSION: Further study and standardization of quality indicators for palliative RT utilization near EOL is required. Whilst clarification occurs, physicians should consider the prognosis of patients with incurable lung cancer and the realistic expectation of benefit from palliative thoracic RT when considering treatment indications and fractionation schedules.

Burr hole washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis.

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients' clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.

Crucifixion and median neuropathy.

Crucifixion as a means of torture and execution was first developed in the 6th century B.C. and remained popular for over 1000 years. Details of the practice, which claimed hundreds of thousands of lives, have intrigued scholars as historical records and archaeological findings from the era are limited. As a result, various aspects of crucifixion, including the type of crosses used, methods of securing victims to crosses, the length of time victims survived on the cross, and the exact mechanisms of death, remain topics of debate. One aspect of crucifixion not previously explored in detail is the characteristic hand posture often depicted in artistic renditions of crucifixion. In this posture, the hand is clenched in a peculiar and characteristic fashion: there is complete failure of flexion of the thumb and index finger with partial failure of flexion of the middle finger. Such a "crucified clench" is depicted across different cultures and from different eras. A review of crucifixion history and techniques, median nerve anatomy and function, and the historical artistic depiction of crucifixion was performed to support the hypothesis that the "crucified clench" results from proximal median neuropathy due to positioning on the cross, rather than from direct trauma of impalement of the hand or wrist.

Selective use of peri-operative steroids in pituitary tumor surgery: escape from dogma.

OBJECTIVE: Traditional neurosurgical practice calls for administration of peri-operative stress-dose steroids for sellar-suprasellar masses undergoing operative treatment. This practice is considered critical to prevent peri-operative complications associated with hypoadrenalism, such as hypotension and circulatory collapse. However, stress-dose steroids complicate the management of these patients. It has been our routine practice to use stress steroids during surgery only if the patient has clinical or biochemical evidence of hypocortisolism pre-operatively. We wanted to be certain that this practice was safe. METHODS: We present our retrospective analysis from a consecutive series of 114 operations in 109 patients with sellar and/or suprasellar tumors, the majority of whom were managed without empirical stress-dose steroid coverage. Only patients who were hypoadrenal pre-operatively or who had suffered apoplexy were given stress-dose coverage during surgery. We screened for biochemical evidence of hypoadrenalism as a result of surgery by measuring immediate post-operative AM serum cortisol levels. RESULTS: There were no adverse events related to the selective use of cortisol replacement in this patient population. CONCLUSION: Our experience demonstrates that selective use of corticosteroid replacement is safe; it simplifies the management of the patients, and has advantages over empiric "dogmatic" steroid coverage.