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1.
Ophthalmology ; 127(4S): S160-S171, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32200817

RESUMO

CONTEXT: Although widely used for more than 85 years, the efficacy of radiotherapy for Graves' ophthalmopathy (GO) has not been established convincingly. OBJECTIVE: To evaluate the efficacy of radiotherapy for GO. DESIGN: Prospective, randomized, internally controlled, double-blind clinical trial in a tertiary care academic medical center. PARTICIPANTS: The patients were ethnically diverse males and females over age 30 seen in a referral practice. The patients had moderate, symptomatic Graves' ophthalmopathy (mean clinical activity score, 6.2) but no optic neuropathy, diabetes, recent steroid treatment, previous decompression, or muscle surgery. Forty-two of 53 consecutive patients were enrolled after giving informed consent and fulfilling study entry criteria. Eleven eligible patients declined to participate because of inconvenience, desire for alternative therapy, or concern about radiation. INTERVENTION: One randomly selected orbit was treated with 20 Gy of external beam therapy; sham therapy was given to the other side. Six months later, the therapies were reversed. MAIN OUTCOME MEASURES: Every 3 months for 1 year, we measured the volume of extraocular muscle and fat, proptosis, range of extraocular muscle motion, area of diplopia fields, and lid fissure width. Effective treatment for GO will modify one or more of these parameters. RESULTS: No clinically or statistically significant difference between the treated and untreated orbit was observed in any of the main outcome measures at 6 months. At 12 months, muscle volume and proptosis improved slightly more in the orbit that was treated first. CONCLUSIONS: In this group of patients, representative of those for whom radiotherapy is frequently recommended, we were unable to demonstrate any beneficial therapeutic effect. The slight improvement noted in both orbits at 12 months may be the result of natural remission or of radiotherapy, but the changes are of marginal clinical significance.

2.
Oper Neurosurg (Hagerstown) ; 18(2): 136-144, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31250901

RESUMO

BACKGROUND: Surgical resection is typically cited as the optimal treatment of patients with Spetzler-Martin Grade I-II arteriovenous malformation (AVM). OBJECTIVE: To report our experience with single-fraction stereotactic radiosurgery (SRS) for Spetzler-Martin Grade I-II AVM. METHODS: A prospectively maintained registry was reviewed for patients with nonsyndromic Spetzler-Martin Grade I-II AVM having SRS from 1990 to 2011. Patients with <24 mo of follow-up or prior radiotherapy/SRS were excluded, resulting in a study population of 173 patients. Actuarial analysis was performed using the Kaplan-Meier method, and Cox proportional hazards modeling was performed with excellent outcomes (obliteration without new deficits) as the dependent variable. RESULTS: Median post-SRS follow-up was 68 mo (range, 24-275). AVM obliteration was achieved in 132 (76%) after initial SRS. Eleven additional patients achieved obliteration after repeat SRS for an overall obliteration rate of 83%. The rate of obliteration was 60% at 4 yr and 78% at 8 yr. Post-SRS hemorrhage occurred in 7 patients (4%), resulting in 3 minor deficits (2%) and 1 death (<1%). Radiation-induced complications occurred in 5 patients (3%), resulting in minor deficits only. One hundred and thirty-seven patients (79%) had excellent outcomes at last follow-up. CONCLUSION: SRS is a safe and effective treatment for patients with Spetzler-Martin Grade I-II AVM. Selection bias is likely a contributing factor to explain the superior outcomes generally noted in reported series of microsurgery for patients with low grade AVM.

3.
J Neurosurg ; : 1-8, 2019 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-31653808

RESUMO

OBJECTIVE: Stereotactic radiosurgery (SRS) is an accepted treatment option for patients with benign parasellar tumors. Here, the authors' objective was to determine the risk of developing new or progressive internal carotid artery (ICA) stenosis or occlusion after single-fraction SRS for cavernous sinus meningioma (CSM) or growth hormone-secreting pituitary adenoma (GHPA). METHODS: The authors queried their prospectively maintained registry for patients treated with single-fraction SRS for CSM or GHPA in the period from 1990 to 2015. Study criteria included no prior irradiation and ≥ 12 months of post-SRS radiological follow-up. Pre-SRS grading of ICA involvement was applied according to the 1993 classification schemes of Hirsch for CSM or Knosp for GHPA. RESULTS: The authors conducted a retrospective review of 283 patients, 155 with CSMs and 128 with GHPAs. Ninety-three (60%) CSMs were Hirsch category 2 and 3 tumors; 97 (76%) GHPAs were Knosp grade 2-4 tumors. Median follow-up after SRS was 6.6 years (IQR 1-24.9 years). No GHPA or category 1 CSM developed ICA stenosis or occlusion. Three (5.2%) patients with category 2 CSMs had asymptomatic ICA stenosis (n = 2) or occlusion (n = 1); 1 (1.1%) category 2 CSM patient had transient ischemic symptoms. Five (14.3%) category 3 CSMs progressed to ICA occlusion (4 asymptomatic, 1 symptomatic). The median time to stenosis/occlusion was 4.8 years (IQR 1.8-7.6). Five- and 10-year risks of ICA stenosis/occlusion in category 2 and 3 CSM patients were 7.5% and 12.4%, respectively. Five- and 10-year risks of ischemic stroke from ICA stenosis/occlusion in category 2 and 3 CSM patients were both 1.2%. Multivariate analysis showed patient age (HR 0.92, 95% CI 0.86-0.98, p = 0.01), meningioma pathology (HR and 95% CI not defined, p = 0.03), and pre-SRS carotid category (HR 4.51, 95% CI 1.77-14.61, p = 0.004) to be associated with ICA stenosis/occlusion. Internal carotid artery stenosis/occlusion was not related to post-SRS tumor growth (HR and 95% CI not defined, p = 0.41). CONCLUSIONS: New or progressive ICA stenosis/occlusion was common after SRS for CSM but was not observed after SRS for GHPA, suggesting a tumor-specific mechanism unrelated to radiation dose. Pre-SRS ICA encasement or constriction increases the risk of ICA stenosis/occlusion; however, the risk of ischemic complications is very low.

4.
J Neurooncol ; 144(2): 325-332, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31254265

RESUMO

PURPOSE: Spindle cell oncocytoma (SCO) is a rare benign pituitary tumor. No patient series regarding stereotactic radiosurgery (SRS) for SCO has been published. We report the clinical outcomes of SCO treated with single-fraction SRS, as well as a systematic review of the literature. METHODS: Retrospective cohort series and systematic literature review. RESULTS: Five patients (four male, one female) having single-fraction SRS for persistent or recurrent SCO between 2002 and 2018. Median age was 56 (range 54-79) years. Pre-SRS treatments included transsphenoidal resection (TSR) (n = 3), multiple TSR (n = 1), and TSR, radiotherapy, and craniotomy (n = 1). Median target volume was 4.7 (range 1.8-8.4) cm3, with a median tumor margin dose of 17 (range 14-20) Gy. Median follow-up was 24 (range 10-69) months. All radiation-naïve patients achieved tumor control after SRS; tumor progression was noted 24 months after SRS in one patient who failed prior radiotherapy. No radiation-induced complications were observed after SRS. Systematic literature review of 43 cases in addition to the five cases presented here showed that tumor progression/recurrence was more frequent after STR compared to GTR (P < 0.001). Ten previous cases of radiotherapy for SCO have been reported, but most did not detail radiation volumes, doses, or outcomes. CONCLUSIONS: SCO are uncommon sellar lesions with a propensity for progression or recurrence. Based on the clinically aggressive course of these tumors, adjuvant SRS after STR or at the time of tumor recurrence should be considered. Further case accumulation and follow-up is required to better understand the long-term treatment outcomes after single-fraction SRS for these rare tumors.


Assuntos
Adenoma Oxífilo/cirurgia , Neoplasias Hipofisárias/cirurgia , Radiocirurgia/métodos , Adenoma Oxífilo/patologia , Humanos , Neoplasias Hipofisárias/patologia , Prognóstico
5.
Neurosurgery ; 80(4): 543-550, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28362923

RESUMO

BACKGROUND: Radiation-based treatment options of large intracranial arteriovenous malformations (AVM) must balance the likelihood of obliteration with the risk of adverse radiation effects (ARE). OBJECTIVE: To analyze the efficacy and risks of volume-staged stereotactic radiosurgery (VS-SRS) for AVM. METHODS: Retrospective study of 34 AVM patients having VS-SRS between 1997 and 2012. A median of 2 stages (range, 2-4) was used to treat a median AVM volume of 22.2 cm 3 (range, 7.4-56.7). The median AVM margin dose was 16 Gy (range, 14-18); the median radiosurgery-based AVM score was 2.81 (range, 1.54-6.45). The median follow-up after VS-SRS was 8.2 years (range, 3-13.3). RESULTS: Nidus obliteration was noted in 18 patients (53%) after VS-SRS. The rate of obliteration was 14% at 3 years, 54% at 5 years, and 75% at 7 years. Six patients (18%) had 11 bleeds after VS-SRS. Two patients (6%) remained neurologically stable, 2 (6%) patients had significant deficits, and 2 patients (6%) died. The actuarial risk of a first bleed after VS-SRS was 6% at 1 year, 12% at 3 years, and 19% at 7 years. Six patients (18%) underwent repeat SRS; all achieved nidus obliteration for an overall cure rate of 71%. Two patients (6%) had a permanent ARE after VS-SRS or repeat SRS. CONCLUSION: VS-SRS permitted large volume intracranial AVM to be treated with a low rate of ARE. Further study is needed on dose escalation and decreasing the treatment volume per stage to determine if this will increase the rate of obliteration with this technique.


Assuntos
Malformações Arteriovenosas Intracranianas/cirurgia , Radiocirurgia/métodos , Técnicas Estereotáxicas , Adolescente , Adulto , Criança , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
6.
Int J Radiat Oncol Biol Phys ; 97(5): 919-923, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28333013

RESUMO

PURPOSE: To determine the risk of radiation-induced tumors or malignant transformation after single-fraction intracranial stereotactic radiosurgery (SRS). METHODS AND MATERIALS: We performed a retrospective review of 1837 patients who received single-fraction SRS for arteriovenous malformation or benign tumor (meningioma, vestibular schwannoma, pituitary adenoma, glomus tumor) at a single center between 1990 and 2009. Patients were excluded if they refused research authorization (n=31), had a genetic predisposition to tumor development (n=84), received prior or concurrent radiation therapy (n=79), or had less than 5 years of imaging follow-up after SRS (n=501). The median imaging follow-up period for the remaining 1142 patients was 9.0 years (range, 5-24.9 years). RESULTS: No radiation-induced tumors were identified in 11,264 patient-years of follow-up after SRS. The risk of a radiation-induced tumor developing after SRS was 0.0% at 5 years (95% confidence interval [CI], 0.0%-0.4%), 0.0% at 10 years (95% CI, 0.0%-0.9%), and 0.0% at 15 years (95% CI, 0.0%-2.8%). Malignant transformation occurred in 7 of 316 meningioma patients (2.2%) and 1 of 358 vestibular schwannoma patients (0.3%) at a median of 4.9 years (range, 2.8-13.8 years) after SRS. No cases of malignant transformation were noted in patients with pituitary adenomas (n=188) or glomus tumors (n=47). The 5-, 10-, and 15-year risk of malignant transformation was 0.5% (95% CI, 0.0%-0.9%), 0.8% (95% CI, 0.0%-1.8%), and 2.4% (95% CI, 0.0%-5.5%), respectively. Patients who underwent prior resection (hazard ratio, 14.56; 95% CI, 1.79-118.33; P=.01) and who had meningioma pathology (hazard ratio, 11.72; 95% CI, 1.44-96.15; P=.02) were at increased risk of malignant transformation. CONCLUSIONS: The risk of radiation-induced tumors or malignant transformation after SRS is very low and should not be used as a justification for choosing alternative treatment approaches (surgical resection, observation) over SRS for appropriate patients.


Assuntos
Neoplasias Encefálicas/epidemiologia , Neoplasias Encefálicas/terapia , Transformação Celular Neoplásica/efeitos da radiação , Irradiação Craniana/estatística & dados numéricos , Neoplasias Induzidas por Radiação/epidemiologia , Radiocirurgia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/prevenção & controle , Criança , Pré-Escolar , Fracionamento da Dose de Radiação , Relação Dose-Resposta à Radiação , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Minnesota , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
7.
J Neurosurg ; 126(3): 852-858, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27058199

RESUMO

OBJECTIVE Successful stereotactic radiosurgery (SRS) for the treatment of arteriovenous malformations (AVMs) results in nidus obliteration without new neurological deficits related to either intracranial hemorrhage (ICH) or radiation-induced complications (RICs). In this study the authors compared 5 AVM grading scales (Spetzler-Martin grading scale, radiosurgery-based AVM score [RBAS], Heidelberg score, Virginia Radiosurgery AVM Scale [VRAS], and proton radiosurgery AVM scale [PRAS]) at predicting outcomes after SRS. METHODS The study group consisted of 381 patients with sporadic AVMs who underwent Gamma Knife SRS between January 1990 and December 2009; none of the patients underwent prior radiation therapy. The primary end point was AVM obliteration without a decline in modified Rankin Scale (mRS) score (excellent outcome). Comparison of the area under the receiver operating characteristic curve (AUC) and accuracy was performed between the AVM grading scales and the best linear regression model (generalized linear model, elastic net [GLMnet]). RESULTS The median radiological follow-up after initial SRS was 77 months; the median clinical follow-up was 93 months. AVM obliteration was documented in 297 patients (78.0%). Obliteration was 59% at 4 years and 85% at 8 years. Fifty-five patients (14.4%) had a decline in mRS score secondary to RICs (n = 29, 7.6%) or ICH (n = 26, 6.8%). The mRS score declined by 10% at 4 years and 15% at 8 years. Overall, 274 patients (71.9%) had excellent outcomes. There was no difference between the AUC for the GLMnet (0.69 [95% CI 0.64-0.75]), RBAS (0.68 [95% CI 0.62-0.74]), or PRAS (0.69 [95% CI 0.62-0.74]). Pairwise comparison for accuracy showed no difference between the GLMnet and the RBAS (p = 0.08) or PRAS (p = 0.16), but it did show a significant difference between the GLMnet and the Spetzler-Martin grading system (p < 0.001), Heidelberg score (p < 0.001), and the VRAS (p < 0.001). The RBAS and the PRAS were more accurate when compared with the Spetzler-Martin grading scale (p = 0.03 and p = 0.01), Heidelberg score (p = 0.02 and p = 0.02), and VRAS (p = 0.03 and p = 0.02). CONCLUSIONS SRS provides AVM obliteration without functional decline in the majority of treated patients. AVM grading scales having continuous scores (RBAS and PRAS) outperformed integer-based grading systems in the prediction of AVM obliteration without mRS score decline after SRS.


Assuntos
Malformações Arteriovenosas Intracranianas/diagnóstico , Malformações Arteriovenosas Intracranianas/radioterapia , Radiocirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Adulto Jovem
8.
Neurosurgery ; 78(4): 499-509, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26990410

RESUMO

BACKGROUND: Stereotactic radiosurgery (SRS) has been performed on patients with cerebral arteriovenous malformations (AVMs) for over 40 years. OBJECTIVE: To evaluate the impact of treatment period on obliteration, intracranial hemorrhage (ICH), and radiation-induced complications (RICs). METHODS: Retrospective comparison of 381 AVM patients having SRS during a 20-year period (group 1, January 1990 through March 1997, n = 160; group 2, April 1997 through December 2009, n = 221). The median radiological and clinical follow-up after initial SRS was 77 months and 93 months, respectively. RESULTS: Obliteration was 59.1% at 4 years and 85.1% at 8 years. Obliteration was more common in patients with hemispheric or cerebellar AVMs (P = .001), smaller prescription isodose volume (PIV) (P < .001), and group 1 patients (P < .001). The ICH rate was 7.7% at 4 years and 10.6% at 8 years. ICH was more common in older patients (P = .02), patients with deep AVM (P = .01), and larger PIV (P < .001). There was no difference in the ICH rate between the treatment groups (P = .18). The rate of permanent RICs was 4.4% at 4 years and 8.6% at 8 years. RICs were more common with larger PIVs (P < .001) and group 1 patients (P = .02). There was no difference in the number of patients having obliteration without new deficits between the 2 treatment periods (68.8% vs 73.3%, P = .33). CONCLUSION: Advances in SRS procedures over the past 20 years have resulted in a lower risk of RIC, but fewer patients had AVM obliteration. Increasing the prescription dose for patients with medium- and large-volume AVMs by using current conformal dose-planning techniques may improve the obliteration rate while maintaining a low risk of RICs.


Assuntos
Malformações Arteriovenosas Intracranianas/cirurgia , Procedimentos Neurocirúrgicos/métodos , Radiocirurgia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Relação Dose-Resposta à Radiação , Feminino , Seguimentos , Humanos , Malformações Arteriovenosas Intracranianas/complicações , Hemorragias Intracranianas/etiologia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Lesões por Radiação , Radiocirurgia/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
9.
Pract Radiat Oncol ; 6(4): e117-26, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26825250

RESUMO

INTRODUCTION: Establishment of standards within a practice and across disease site groups for nomenclatures, prescription formatting, and measured dose-volume histogram (DVH) metrics is a key enabling step for creating software and database solutions to make routine aggregation of dosimetric data for all patients treated in a practice, practical. A process of physician-driven, iterative dialogs coupled with development of technical tools is required to implement the cultural and procedural changes. The cumulative reward for this effort is a database that can be used for defining practice norms, benchmarking against national standards, and tracking dosimetric effects of longitudinal practice pattern changes. METHODS AND MATERIALS: A 4-year project was carried out to develop and introduce standardizations, modify processes, and develop computer-based tools for reporting, aggregation, and analysis of prescription and DVH metrics. Physician disease site groups developed 42 target and 81 normal tissue templates. From the database of 32,002 DVH metrics, benchmarking was illustrated for a subgroup of breast (281) and prostate (324) patients treated with conventional fractionation over a 16-month period. Breast patients were segregated according to prescription template used: simple (S, tangents only) vs complex (C, tangents + supraclavicular ± intramammary nodes) and left (S-L or C-L) versus right (S-R or C-R). RESULTS: Prostate patients' median and 50% confidence intervals (CIs) for bladder, stated according to the nomenclature: the percentage of bladder volume receiving doses of ≥40 Gy (V40[%]), V65Gy[%], V70Gy[%], V75Gy[%], and V80Gy[%] were 45.5 (24.9-57.0), 15.6 (9.0-23.8), 7.6 (3.3-13.6), 2.0 (0.0-7.9), and 0.0 (0.0-1.4), respectively. Values for rectum: V50Gy[%], V60 Gy[%], V65Gy[%], V70Gy[%], and V75Gy[%] were 37.1 (27.8-43.5), 21.8 (15.6-25.5), 14.6 (9.6-18.0), 7.7 (1.9-12.3), and 1.0 (0-7.0), respectively. For breast patients, heart:mean Gray values were 1.5 (1.0-2.0), 3.1 (2.2-4.8), 0.4 (0.3-0.7), and 1.1 (0.8-2.2) for S-L, C-L, S-R, and C-R, respectively. Longitudinal, moving window plots of median, 50% CI, and 90% CI for 6-month periods demonstrated the effect of practice changes to reduce heart doses. CONCLUSIONS: Standardization was challenging as a practice change, but has resulted in significant improvements for both our clinical and research efforts.


Assuntos
Bases de Dados como Assunto/normas , Software/normas , Feminino , Humanos , Bases de Conhecimento , Masculino , Terminologia como Assunto
10.
J Neurooncol ; 120(1): 95-102, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25005529

RESUMO

Meningeal hemangiopericytomas (M-HPC) are challenging tumors with a high rate of recurrence despite surgical resection and external beam radiotherapy (EBRT). To better understand the role of single-fraction stereotactic radiosurgery (SRS) for patients with M-HPC, we reviewed our experience with 22 patients (12 men, 10 women) from 1990 until 2010. Twelve patients (55%) underwent a single SRS procedure, whereas 10 patients (45%) had more than one SRS procedure (range 2-6). In total, 47 SRS procedures were performed to treat 64 tumors. Fourteen patients (64%) had undergone prior EBRT (median dose, 56.0 Gy). Follow-up after the initial SRS (median, 66 months) was censored at the time of death (n = 15) or last clinical evaluation (n = 7). Eleven patients (50 %) died of intracranial tumor progression (n = 10) or treatment-related complications (n = 1). One patient (5%) died of systemic disease progression. Disease-specific survival (DSS) at 1-, 3- and 5-years after SRS was 96, 82, and 61%, respectively. Prior EBRT (HR 9.0, 95% CI 1.1-78.1, p < 0.05) and larger initial tumor volume (HR 1.09, 95% CI 1.02-1.2, p = 0.02) were associated with worse DSS. Local tumor control (LTC) after SRS at 1-, 3-, and 5-years was 89, 68, and 59%, respectively. Improved LTC was noted in patients who had not undergone prior EBRT (HR 6.3, 95% CI 2.1-19.5, p = 0.001). One patient (5%) had symptomatic radiation-relation complications after SRS. Overall, single-fraction SRS was effective in providing LTC for more than half of recurrent or residual M-HPC at 5-years after the procedure. Repeat SRS is often required secondary to either distant or local tumor progression.


Assuntos
Hemangiopericitoma/cirurgia , Neoplasias Meníngeas/cirurgia , Complicações Pós-Operatórias , Radiocirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fracionamento da Dose de Radiação , Feminino , Seguimentos , Hemangiopericitoma/mortalidade , Hemangiopericitoma/patologia , Humanos , Masculino , Neoplasias Meníngeas/mortalidade , Neoplasias Meníngeas/patologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Taxa de Sobrevida , Carga Tumoral
11.
Neurosurgery ; 75(4): 456-60; discussion 460, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24902082

RESUMO

BACKGROUND: The risk of radiation-induced optic neuropathy (RION) is the primary limitation of single-fraction stereotactic radiosurgery (SRS) for many patients with parasellar lesions. OBJECTIVE: To define the normal tissue complication probability of the anterior visual pathways (AVPs) after single-fraction SRS. METHODS: Retrospective review comparing visual function before and after SRS in 133 patients (266 sides) with pituitary adenomas having SRS between October 2007 and July 2012. Patients with prior radiation therapy or SRS were excluded. The median follow-up after SRS was 32 months. RESULTS: The median maximum point dose to the AVP was 9.2 Gy (interquartile range [IQR], 6.9-10.8). One hundred seventy-four sides (65%) received >8 Gy: the median 8-Gy volume was 15.8 mm³ (IQR, 3.7-36.2). Ninety-four sides (35%) received >10 Gy; the median 10-Gy volume was 1.6 mm³ (IQR, 0.5-5.3). Twenty-nine sides (11%) received >12 Gy; the median 12-Gy volume was 0.1 mm³ (IQR, 0.1-0.6). No patient had a RION after SRS. The chances of developing a RION at the 8-Gy, 10-Gy, and 12-Gy volumes (95% confidence interval) in this series were 0% to 2.6%, 0% to 4.7%, and 0% to 13.9%, respectively. CONCLUSION: The AVP in patients without prior radiation treatments can safely receive radiation doses up to 12 Gy with a low risk of RION. Although additional studies are needed to better delineate the normal tissue complication probability of the AVP, adherence to the AVP radiation tolerance guidelines developed 20 years ago (8 Gy) limits the applicability and potentially the effectiveness of single-fraction SRS for patients with lesions in the parasellar region.


Assuntos
Adenoma/cirurgia , Doenças do Nervo Óptico/epidemiologia , Neoplasias Hipofisárias/cirurgia , Radiocirurgia/efeitos adversos , Adulto , Idoso , Relação Dose-Resposta à Radiação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
12.
Neurooncol Pract ; 1(1): 22-28, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26034611

RESUMO

BACKGROUND: To assess the risk of cerebrovascular accidents (CVAs) and second brain tumors (SBTs) in patients with pituitary adenoma after surgery or radiotherapy. METHODS: A cohort of 143 people from Olmsted County, who were diagnosed with pituitary adenoma between 1933 and 2000, was studied. Only patients from Olmsted County were included because of the unique nature of medical care in Olmsted County, which allows the ascertainment of virtually all cases of pituitary adenoma for this community's residents and comparisons to the general population in the county. Surgical resection was performed in 76 patients, 29 patients underwent radiotherapy (with 21 undergoing both surgery and radiotherapy), 5 patients were reirradiated, and 59 patients were managed conservatively and observed. RESULTS: Median follow-up was 15.5 years. There was no difference in CVA-free survival between treatment groups. On univariate analysis age > 60 years (hazard ratio [HR], 11.93; 95% CI, 6.26-23.03; P < .001); male sex (HR, 3.67; 95% CI, 2.03-6.84; P < .001), and reirradiation (HR, 3.41; 95% CI, 1.05-9.68; P = .04) were associated with worse CVA-free survival. In multivariate analysis, only age > 60 years was associated with worse CVA-free survival. Compared with the general population, there was a 4-fold increase in the rate of CVAs in pituitary adenoma patients (HR, 4.2; 95% CI, 2.8-6.1). Two patients developed SBT (an irradiated patient and a surgically managed patient). CONCLUSION: CVA is a significant risk for patients with pituitary tumors, but treatment does not seem to impact the risk. Even with long-term follow-up, SBTs are a rare event regardless of treatment modality.

13.
Am J Clin Oncol ; 37(1): 81-5, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23111357

RESUMO

OBJECTIVES: To review outcomes for patients who received intraoperative radiotherapy (IORT) for upper-extremity sarcoma. METHODS: We identified patients with upper-extremity tumors who were treated with external beam radiotherapy, surgery, and IORT, with or without chemotherapy. Kaplan-Meier estimates for overall survival (OS), central control (CC), local control (LC), and distant control (DC) were obtained. RESULTS: Sixty-one patients were identified. Median age was 50 years (range, 13 to 95 y). Median follow-up was 5.9 years. Eleven patients had gross (R2; n=1) or microscopic (R1; n=10) disease at the time of IORT. IORT doses ranged from 7.50 to 20.00 Gy. External beam radiotherapy doses ranged from 19.80 to 54.00 Gy. OS at 5 and 10 years was 72% and 58%, respectively. LC at 5 and 10 years was 91% and 88%, respectively. DC at 5 and 10 years was 80% and 77%, respectively. Patients treated for recurrent disease had inferior 5-year OS compared with patients with first diagnoses (63% vs. 74%; P=0.02) and lower 5-year LC (67% vs. 94%; P<0.01). For patients with R1 or R2 resections, LC at 5 and 10 years was 100% and 86%, respectively; for patients with R0 resections, LC was 89% at both 5 and 10 years (P=0.98). Severe toxicity attributable to treatment was noted for 4 patients (7%). CONCLUSIONS: For upper-extremity sarcoma, treatment including IORT was associated with excellent LC, limb preservation, and survival. LC rates were excellent for patients with positive margins after resection. Patients with recurrent disease had worse outcomes, but limb preservation was achievable for most patients.


Assuntos
Recidiva Local de Neoplasia/radioterapia , Recidiva Local de Neoplasia/cirurgia , Tratamentos com Preservação do Órgão/métodos , Sarcoma/radioterapia , Sarcoma/cirurgia , Extremidade Superior , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Período Intraoperatório , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias , Dosagem Radioterapêutica , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos , Sarcoma/mortalidade , Sarcoma/patologia , Sarcoma/prevenção & controle , Resultado do Tratamento
14.
Int J Radiat Oncol Biol Phys ; 87(3): 524-7, 2013 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-24074926

RESUMO

PURPOSE: To determine the long-term risk of radiation-induced optic neuropathy (RION) in patients having single-fraction stereotactic radiosurgery (SRS) for benign skull base tumors. METHODS AND MATERIALS: Retrospective review of 222 patients having Gamma Knife radiosurgery for benign tumors adjacent to the anterior visual pathway (AVP) between 1991 and 1999. Excluded were patients with prior or concurrent external beam radiation therapy or SRS. One hundred twenty-nine patients (58%) had undergone previous surgery. Tumor types included confirmed World Health Organization grade 1 or presumed cavernous sinus meningioma (n=143), pituitary adenoma (n=72), and craniopharyngioma (n=7). The maximum dose to the AVP was ≤8.0 Gy (n=126), 8.1-10.0 Gy (n=39), 10.1-12.0 Gy (n=47), and >12 Gy (n=10). RESULTS: The mean clinical and imaging follow-up periods were 83 and 123 months, respectively. One patient (0.5%) who received a maximum radiation dose of 12.8 Gy to the AVP developed unilateral blindness 18 months after SRS. The chance of RION according to the maximum radiation dose received by the AVP was 0 (95% confidence interval [CI] 0-3.6%), 0 (95% CI 0-10.7%), 0 (95% CI 0-9.0%), and 10% (95% CI 0-43.0%) for patients receiving ≤8 Gy, 8.1-10.0 Gy, 10.1-12.0 Gy, and >12 Gy, respectively. The overall risk of RION in patients receiving >8 Gy to the AVP was 1.0% (95% CI 0-6.2%). CONCLUSIONS: The risk of RION after single-fraction SRS in patients with benign skull base tumors who have no prior radiation exposure is very low if the maximum dose to the AVP is ≤12 Gy. Physicians performing single-fraction SRS should remain cautious when treating lesions adjacent to the AVP, especially when the maximum dose exceeds 10 Gy.


Assuntos
Nervo Óptico/efeitos da radiação , Lesões por Radiação/epidemiologia , Radiocirurgia/efeitos adversos , Neoplasias da Base do Crânio/cirurgia , Adenoma/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Craniofaringioma/cirurgia , Seguimentos , Humanos , Incidência , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Pessoa de Meia-Idade , Neoplasias Hipofisárias/cirurgia , Tolerância a Radiação , Radiocirurgia/métodos , Dosagem Radioterapêutica , Estudos Retrospectivos , Medição de Risco , Adulto Jovem
15.
Neurosurg Clin N Am ; 24(4): 499-507, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24093568

RESUMO

Stereotactic radiosurgery (SRS) has been performed for intracranial meningiomas for more than 30 years. Small to moderate-sized meningiomas are generally considered good candidates for SRS because of their neuro-imaging and radiobiological characteristics. Patient selection is critical for successful meningioma SRS. Factors related to tumor control and radiation-related complications in patients with WHO grade I or presumed meningiomas include history of prior surgery, tumor volume, and tumor location. Patients with small volume, nonoperated skull-base or tentorial meningiomas typically have the best outcomes after SRS.


Assuntos
Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Radiocirurgia/métodos , Feminino , Humanos , Masculino , Neoplasias Meníngeas/patologia , Meningioma/patologia , Resultado do Tratamento
16.
J Neurosurg ; 119(3): 675-82, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23808540

RESUMO

OBJECT: Stereotactic radiosurgery (SRS) is an important treatment option for patients with cavernous sinus meningiomas (CSM). To analyze factors associated with local tumor control and complications after single-fraction SRS, the authors reviewed cases involving patients treated with Gamma Knife SRS between 1990 and 2008. METHODS: Excluded were patients with WHO Grade II or III tumors, radiation-induced tumors, multiple meningiomas, neurofibromatosis Type 2, and prior or concurrent radiotherapy. Five patients were lost to follow-up and 3 patients refused research authorization. The remaining 115 patients (29 men, 86 women) had either histologically confirmed WHO Grade I (n = 46, 40%) or presumed (n = 69, 60%) CSM. The median treatment volume was 9.3 cm(3) (range 1.3-42.2 cm(3)). The median margin dose was 16 Gy (range 12-20 Gy). The median follow-up after SRS was 89 months (range 12-251 months). Thirty-nine patients (34%) had 10 or more years of follow-up after SRS. RESULTS: Six patients (5%) had tumor progression (in field, n = 3; marginal, n = 3) at a median of 74 months (range 42-145 months) after SRS. The local tumor control rate was 99% at 5 years and 93% at 10 years after SRS. No analyzed factor was associated with local control after SRS. Fourteen patients (12%) had permanent complications at a median onset of 23 months (range 2-146 months) including trigeminal dysfunction (n = 9), diplopia (n = 2), ischemic stroke (n = 2), and hypopituitarism (n = 1). The 2-year, 5-year, and 10-year rates of complications were 7%, 10%, and 15%, respectively. Multivariate analysis found larger treatment volume (HR 1.1, 95% CI 1.02-1.2, p = 0.01) to be associated with complications after SRS. The complication rate for patients with a treatment volume of 9.3 cm(3) or less was 3% (2 of 58 cases) compared with 21% (12 of 57 cases) for patients with a treatment volume greater than 9.4 cm(3). CONCLUSIONS: Single-fraction SRS at the radiation doses used in this series provided durable tumor control for patients with benign CSM. Larger tumor volume remains the primary factor associated with complications after single-fraction SRS of benign CSM despite advancements in SRS technique.


Assuntos
Seio Cavernoso/patologia , Neoplasias Meníngeas/patologia , Meningioma/patologia , Radiocirurgia/normas , Carga Tumoral , Adulto , Idoso , Idoso de 80 Anos ou mais , Seio Cavernoso/cirurgia , Feminino , Humanos , Masculino , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Pessoa de Meia-Idade , Radiocirurgia/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
17.
Int J Radiat Oncol Biol Phys ; 86(1): 18-26, 2013 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-23040219

RESUMO

Charged particle therapy (CPT) delivered with either protons, helium ions, or carbon ions, has been used to treat uveal melanoma. The present analysis was performed to systematically evaluate the efficacy and adverse effects of CPT for uveal melanoma. We searched EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus and cross-referenced recent systematic reviews through January 2012. Two independent reviewers identified clinical trials and observational studies of CPT (protons, helium ions, and carbon ions). These reviewers extracted data and assessed study quality. Twenty-seven studies enrolling 8809 uveal melanoma patients met inclusion criteria. The rate of local recurrence was significantly less with CPT than with brachytherapy (odds ratio [OR] = 0.22, 95% confidence interval [CI], 0.21-0.23). There were no significant differences in mortality or enucleation rates. Results were robust in multiple sensitivity analyses. CPT was also associated with lower retinopathy and cataract formation rates. Data suggest better outcomes may be possible with charged particle therapy with respect to local recurrence, retinopathy, and cataract formation rates. The overall quality of the evidence is low, and higher quality comparative effectiveness studies are needed to provide better evidence.


Assuntos
Radioterapia com Íons Pesados/métodos , Hélio/uso terapêutico , Melanoma/radioterapia , Terapia com Prótons/métodos , Neoplasias Uveais/radioterapia , Enucleação Ocular/estatística & dados numéricos , Radioterapia com Íons Pesados/efeitos adversos , Hélio/efeitos adversos , Humanos , Terapia com Prótons/efeitos adversos , Resultado do Tratamento
18.
World Neurosurg ; 80(3-4): 371-7, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-22381855

RESUMO

OBJECTIVE: To assess the outcome of stereotactic radiosurgery (SRS) for patients with benign skull base tumors and trigeminal-related facial pain. METHODS: We undertook a retrospective review of 31 consecutive patients (25 women, 6 men) with benign skull base tumors and trigeminal pain who underwent SRS between 1991 and 2008. The tumors included 17 posterior fossa meningiomas, 9 cavernous sinus meningiomas, and 5 trigeminal schwannomas. The median patient age was 62 years (range, 17-81 years). In all cases the tumor was the primary target for SRS. The median follow-up after SRS was 50 months (range, 12-184 months). RESULTS: The actuarial tumor control rate after SRS was 95% at both 3 years and 5 years. Eighteen patients (58%) initially achieved complete resolution of trigeminal pain. Higher maximum dose was associated with initial complete pain resolution on a multivariate analysis. However, 7 patients had recurrent pain during follow-up. At last follow-up, only 7 patients (23%) remained pain-free off medications. Further treatment in addition to medical therapy was required for 6 patients (19%). CONCLUSION: Although SRS offers excellent radiographic tumor control for benign skull base tumors, durable relief of tumor-related trigeminal pain without medication was noted in only one-fourth of patients at last follow-up.


Assuntos
Dor Facial/etiologia , Dor Facial/cirurgia , Radiocirurgia/métodos , Neoplasias da Base do Crânio/complicações , Neuralgia do Trigêmeo/etiologia , Neuralgia do Trigêmeo/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Medição da Dor , Radiocirurgia/efeitos adversos , Estudos Retrospectivos , Neoplasias da Base do Crânio/patologia , Neoplasias da Base do Crânio/cirurgia , Resultado do Tratamento , Adulto Jovem
19.
Radiat Oncol ; 7: 174, 2012 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-23083010

RESUMO

Over the past 20 years, several proton beam treatment programs have been implemented throughout the United States. Increasingly, the number of new programs under development is growing. Proton beam therapy has the potential for improving tumor control and survival through dose escalation. It also has potential for reducing harm to normal organs through dose reduction. However, proton beam therapy is more costly than conventional x-ray therapy. This increased cost may be offset by improved function, improved quality of life, and reduced costs related to treating the late effects of therapy. Clinical research opportunities are abundant to determine which patients will gain the most benefit from proton beam therapy. We review the clinical case for proton beam therapy. SUMMARY SENTENCE: Proton beam therapy is a technically advanced and promising form of radiation therapy.


Assuntos
Neoplasias/radioterapia , Terapia com Prótons , Humanos
20.
Neurosurgery ; 71(3): 604-12; discussion 613, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22710378

RESUMO

BACKGROUND: Stereotactic radiosurgery (SRS) of benign intracranial meningiomas is an accepted management option for well-selected patients. OBJECTIVE: To analyze patients who had single-fraction SRS for benign intracranial meningiomas to determine factors associated with tumor control and neurologic complications. METHODS: Retrospective review was performed of 416 patients (304 women/112 men) who had single-fraction SRS for imaging defined (n = 252) or confirmed World Health Organization grade I (n = 164) meningiomas from 1990 to 2008. Excluded were patients with radiation-induced tumors, multiple meningiomas, neurofibromatosis type 2, and previous or concurrent radiotherapy. The majority of tumors (n = 337; 81%) involved the cranial base or tentorium. The median tumor volume was 7.3 cm; the median tumor margin dose was 16 Gy. The median follow-up was 60 months. RESULTS: The disease-specific survival rate was 97% at 5 years and 94% at 10 years. The 5- and 10-year local tumor control rate was 96% and 89%, respectively. Male sex (hazard ratio [HR]: 2.5, P = .03), previous surgery (HR: 6.9, P = .002) and patients with tumors located in the parasagittal/falx/convexity regions (HR: 2.8, P = .02) were negative risk factors for local tumor control. In 45 patients (11%) permanent radiation-related complications developed at a median of 9 months after SRS. The 1- and 5-year radiation-related complication rate was 6% and 11%, respectively. Risk factors for permanent radiation-related complication rate were increasing tumor volume (HR: 1.05, P = .008) and patients with tumors of the parasagittal/falx/convexity regions (HR: 3.0, P = .005). CONCLUSION: Single-fraction SRS at the studied dose range provided a high rate of tumor control for patients with benign intracranial meningiomas. Patients with small volume, nonoperated cranial base or tentorial meningiomas had the best outcomes after single-fraction SRS.


Assuntos
Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Neoplasias Meníngeas/mortalidade , Neoplasias Meníngeas/patologia , Meningioma/mortalidade , Meningioma/patologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Radiocirurgia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
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