Reoperation for brain metastases.

We report the results of reoperation for brain metastases in 21 patients with recurrent tumors following initial successful resection. The tumor recurrences were local (original site) in 14 patients, and occurred at other sites in the brain in the remaining seven. Time to CNS recurrence ranged from 3 to 30 months. At time of repeat craniotomy, disease was limited to the CNS in 12 (57%) of the patients. Median survival following second craniotomy was 9 months, and the actuarial 2-year survival was 25%. Neurological improvement was seen in two thirds of the patients; the median duration of neurological improvement was 6 months. There was no mortality, and only one patient developed increased deficit following surgery. We conclude that repeat resection of brain metastases is an important therapeutic option in selected patients, and should be considered in symptomatic patients with accessible mass lesions before the use of other experimental treatment.

Spondylectomy for malignant tumors of the spine.

Spondylectomy is the complete surgical removal of all parts of one or more vertebrae above the sacrum. We report our initial experience with spondylectomy in eight patients with malignant tumors of the spine operated on over a 7-year period (1980 to 1986). Four patients had primary neoplasms of the spine, and four others had solitary metastases to the vertebrae. Following surgery, five patients underwent radiation therapy (RT) and chemotherapy depending on histology of the tumor. Radiographic confirmation of tumor resection was obtained on all patients. Pain relief was noted in all patients, and six patients with preoperative neurological deficits improved. There was no surgical mortality, and one patient developed wound dehiscence following surgery. Six of the eight patients are alive with a median follow-up of 36 months, and local control was achieved in six of the eight patients. These preliminary data suggest that malignant tumors of the spine can be completely resected using a staged approach. In potentially responsive tumors, systemic chemotherapy is recommended between the two operations to reduce the risk of systemic dissemination.

Surgical treatment of spinal cord compression in kidney cancer.

Forty-three patients with renal-cell carcinoma underwent treatment for spinal cord compression over a 7-year period. Of these, 32 patients underwent surgery, while 11 patients underwent radiation alone. Before operation, 25 patients had relapsed following prior radiation, while seven others received postoperative radiation. A more aggressive surgical approach, tailored to the site of compression within the spinal canal, was used with the majority undergoing gross total tumor resection by an anterior approach. Immediate stability of the spine was achieved with methyl-methacrylate reconstruction of the resected segments. Preoperative spinal angiography with embolization of hypervascular tumors was carried out in eight patients. Patient parameters in the surgical and irradiated groups were comparable, except that a greater proportion of the radiation alone group had more than one organ system involved (64% v 44%). The median survival of the surgically treated patients was 13 months, compared with 3 months for those treated by radiation alone. In addition, a greater proportion of the surgically treated patients were benefitted neurologically (70%) compared with those treated by radiation (45%). With the development of effective surgical treatment for spinal metastases, early consideration for surgical treatment (before radiation) should be considered in selected patients. Preoperative spinal angiography and embolization are recommended whenever feasible to minimize intraoperative blood loss.

Antitumor and antinociceptive approaches to control cancer pain.

Patients with cancer pain often present with specific clinical syndromes that allow specific anti-tumor approaches. If these approaches are not feasible, neurosurgical procedures for pain relief should be considered. The major advantage of neurosurgical procedures is freedom from the excessive side effects of narcotic therapy. The most durable pain procedure is cordotomy, while intraspinal narcotics offer a rational treatment alternative in selected patients. Spinal and plexopathy syndromes that are amenable to more specific anti-tumor therapy should be looked for, since newer surgical approaches offer the prospect of both pain relief and tumor control.

Neurofibromatosis and optic glioma: clinical and morphological correlations.

Although an association between optic glioma and neurofibromatosis is well recognized, there has been no previous analysis of cases relating the locus of tumor to the presence or absence of von Recklinghausen's disease. This paper presents the results of such an analysis as well as a description of the comparative histology of optic gliomas in patients with and without neurofibromatosis. We conclude that optic gliomas in patients with neurofibromatosis present preferentially as multicentric lesions or as lesions affecting the optic nerve alone without invasion of the chiasm, that these tumors frequently differ morphologically, and that patients with neurofibromatosis and optic glioma may have a clinical course different from that of patients with optic glioma unassociated with neurofibromatosis. Previously published reports are reviewed in light of these observations.

Treatment of neoplastic spinal cord compression: results of a prospective study.

Currently, external radiation and steroid therapy are used in most patients with neoplastic spinal cord compression. Surgery is generally used to treat those who do not respond to radiation therapy. To determine the role of de novo surgery in patients with spinal metastases, a prospective study was undertaken. Over a 4 1/2-year period, the cases of 54 patients with radiologically documented spinal metastases were studied. The sites of tumor origin included soft tissue sarcoma (8 patients), kidney (6 patients), lung (5 patients), breast (5 patients), spine (6 patients), unknown primary site (6 patients), and others (18 patients). Sites of compression included the cervical spine segments in 15 patients, thoracic segments in 23, lumbar in 14, and sacral in 2. Before surgery, 24 patients (44%) were nonambulatory. Three surgical approaches were used: anterior vertebral body resection in 45 patients, laminectomy in 7, and lateral osteotomy in 2. After surgery, 37 patients received external radiation therapy. All patients improved (became ambulatory) after surgery, with 23 of 25 patients surviving at 2 years continuing to be ambulatory. The 30-day mortality rate was 6% (three patients); eight patients (15%) sustained various surgical complications. These results are superior to those reported after external radiation therapy and steroids alone, and they support the concept that de novo surgery be considered in selected patients with spinal metastases.

Giant hemispheric arteriovenous fistula in an infant.

The authors present a case of an 11-month-old boy with a giant hemispheric arteriovenous fistula, which was successfully excised. The pathogenesis of the hydrocephalus present in this case is discussed.

Epidural compression in the spinal canal caused by excessive adipose tissue. A case report.

Excessive deposition of fat in the epidural space is rare. In a recent review of the literature, there were 15 reported cases, 14 were associated with steroid use and one was attributed to hypothyroidism. This report reviews treatment of a patient with symptoms of cauda equina compression caused by epidural adipose tissue. He had no history of steroid use or obvious evidence of an underlying endocrinopathy.

Neurosurgery in the treatment of cancer pain.

Patients with pain syndromes resulting from recurrent or metastatic cancer should be evaluated carefully to determine the cause of their pain and the need for appropriate antitumor treatment. Currently, opioid analgesics are the mainstay of pain control, but side effects limit their use in some patients. When pharmacologic pain control is inadequate or associated with intolerable side effects, neurosurgery should be considered. Currently the implantation of a pump for the intraspinal infusion of opioid analgesics is the most popular procedure, but its usefulness may be limited by the development of opioid tolerance. The most effective ablative pain control procedure at the current time is cordotomy, which is indicated in patients with unilateral pain. Although the place of neurostimulatory procedures in controlling cancer pain is not well established, they are attractive because of their nondestructive nature and potential usefulness in the treatment of bilateral pain syndromes. Specific antitumor surgical procedures should be considered in patients with certain spinal and plexopathy syndromes, because such intervention offers the prospect of both pain relief and tumor control. In this article, the neurosurgical procedures used in the management of cancer pain are reviewed.