Pain Relief-Related Structural Brain Alterations in Trigeminal Neuralgia Induced by Noninvasive Stereotactic Radiosurgery: A Pilot Study.

PURPOSE: Trigeminal neuralgia (TN) is a chronic pain disorder defined by unilateral shock-like pain in at least one division of the trigeminal nerve. Although several studies have investigated structural brain plasticity in patients with TN, treatment-induced alterations remain largely uninvestigated. METHODS AND MATERIALS: Combining T1-weighted magnetic resonance imaging with voxel-based morphometry and multiple-regression analyses, we assessed gray matter maps of patients with TN to investigate changes in gray matter volume (GMV) before and 6 months after stereotactic radiosurgery (SRS). RESULTS: Comparison of pre- and post-SRS GMV of 25 patients with TN (16 women; mean age 67 years) did not yield any significant clusters, suggesting that the effect of SRS intervention itself on gray matter structure may be negligible. Regarding SRS-induced pain relief, we found a significant GMV increase in the left superior frontal gyrus associated with greater degree of pain relief (P = .024) and a trend toward an increase in GMV in the left dorsolateral prefrontal cortex (P = .097). CONCLUSIONS: In this pilot study, we observed significant increases in GMV in the left superior frontal gyrus with SRS-induced improvements in pain and a trend toward an increase in GMV in the dorsolateral prefrontal cortex. Future studies are indicated to validate these findings and determine whether SRS-induced decrease in distracting pain events and subsequent increases in GMV result in improved functionality, decreased dependence on "top-down" control, and improved cognitive/executive balance with amelioration of pain events.

Early motor function after local treatment of brain metastases in the motor cortex region with stereotactic radiotherapy/radiosurgery or microsurgical resection: a retrospective study of two consecutive cohorts.

BACKGROUND: We compared the functional outcome and influential factors of two standard treatment modalities for central cerebral metastases: electrophysiological-controlled microsurgical resection (MSR) and stereotactic radiotherapy/stereotactic radiosurgery (SRT/SRS). METHODS: We performed a database search for central metastasis treatments during the period from January 2008 to September 2012 in two clinical registers: 1) register for intraoperative neuromonitoring (Department of Neurosurgery), and 2) prospective database for SRT/SRS (Department of Radiotherapy). Neurological status before and after treatment, Karnofsky performance index (KPI), histology, tumor localization and volume, and oncological status were standardized and pooled together for analysis. Muscle strength was graded on a scale of 0-5. RESULTS: We identified 27 MSR and 41 SRT/SRS cases from 68 treatments. The MSR-treated patients had significant less muscle strength in the upper and lower extremities before and after the treatment as compared to the patients receiving SRT/SRS. Muscle strength of the extremities did not change for patients receiving SRT/SRS, while MSR patients had significant improvement in lower extremity muscle strength (p = 0.05) and a non-significant improvement in the upper extremities. MSR showed significant improvement in hemiparesis as compared to radiotherapy, but this was accompanied with a significant deterioration of extremity muscle strength after surgery, as compared to SRT/SRS (improvement p = 0.04, deterioration p = 0.10). CONCLUSION: Electrophysiologically guided microsurgery of central metastases had a significantly better functional outcome regarding hemiparesis. However, there was also a trend for less secondary neurological deterioration after SRT/SRS. TRIAL REGISTRATION: ISRCTN81776764. Retrospectively Registered 27 July 2017.

Treatment of acromegaly patients with risk-adapted single or fractionated stereotactic high-precision radiotherapy: High local control and low toxicity in a pooled series.

PURPOSE: The purpose of this work was to evaluate a prospectively initiated two-center protocol of risk-adapted stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) in patients with acromegaly. PATIENTS AND METHODS: In total 35 patients (16 men/19 women, mean age 54 years) were prospectively included in a treatment protocol of SRS [planning target volume (PTV < 4 ccm, > 2 mm to optic pathways = low risk] or SRT (PTV ≥ 4 ccm, ≤ 2 mm to optic pathways = high risk). The mean tumor volume was 3.71 ccm (range: 0.11-22.10 ccm). Based on the protocol guidelines, 21 patients were treated with SRS and 12 patients with SRT, 2 patients received both consecutively. RESULTS: The median follow-up (FU) reached 8 years with a 5-year overall survival (OS) of 87.3% [confidence interval (CI): 70.8-95.6%] and 5-year local control rate of 97.1% (CI: 83.4-99.8%). Almost 80% (28/35) presented tumor shrinkage during FU. Endocrinological cure was achieved in 23% and IGF-1 normalization with reduced medication was achieved in 40% of all patients. An endocrinological response was generally achieved within the first 3 years, but endocrinological cure can require more than 8 years. A new adrenocorticotropic hypopituitarism occurred in 13 patients (46.4%). A new visual field disorder and a new oculomotor palsy occurred in 1 patient, respectively. Patients with occurrence of visual/neurological impairments had a longer FU (p = 0.049). CONCLUSION: Our SRS/SRT protocol proved to be safe and successful in terms of tumor control and protection of the visual system. The timing and rate of endocrine improvements are difficult to predict. One has to accept an unavoidable rate of additional adrenocorticotropic hypopituitarism in the long term.

Risk-adapted single or fractionated stereotactic high-precision radiotherapy in a pooled series of nonfunctioning pituitary adenomas: high local control and low toxicity.

PURPOSE: The purpose of this work was to evaluate a prospectively initiated two-center protocol of risk-adapted single-fraction (SRS) or fractionated radiotherapy (SRT) in patients with nonsecretory pituitary adenomas (NSA). PATIENTS AND METHODS: A total of 73 NSA patients (39 men/34 women) with a median age of 62 years were prospectively included in a treatment protocol of SRS [planning target volume (PTV) < 4 ccm, > 2 mm to optic pathways = low risk] or SRT (PTV ≥ 4 ccm, ≤ 2 mm to optic pathways = high risk) in two Novalis® centers. Mean tumor volume was 7.02 ccm (range 0.58-57.29 ccm). Based on the protocol guidelines, 5 patients were treated with SRS and 68 patients with SRT. RESULTS: Median follow-up (FU) reached 5 years with 5-year overall survival (OS) of 90.4 % (CI 80.2-95 %) and 5-year local control and progression-free survival rates of 100 % (CI 93.3-100 %) and 90.4 % (CI 80.2-95 %), respectively. A post-SRS/SRT new visual disorder occurred in 2 patients (2.7 %), a new oculomotor nerve palsy in one pre-irradiated patient, in 3 patients (4.1 %) a pre-existing visual disorder improved. New complete hypopituitarism occurred in 4 patients (13.8 %) and in 3 patients (25 %) with pre-existing partial hypopituitarism. Pituitary function in 26 % of patients retained normal. Patients with tumor shrinkage (65.75 %) had a significantly longer FU (p = 0.0093). Multivariate analysis confirmed correlation of new hypopituitarism with duration of FU (p = 0.008) and correlation of new hypopituitarism and tumor volume (p = 0.023). No significant influence factors for occurrence of visual disorders were found. CONCLUSION: Our SRS/SRT protocol proved to be safe and successful in terms of tumor control and protection of the visual system, especially for large tumors located close to optic pathways.