Palliative brachytherapy and external beam radiotherapy for dysphagia from esophageal cancer: a nationwide survey in Japan.

BACKGROUND: International guidelines recommend brachytherapy for patients with dysphagia from esophageal cancer, whereas brachytherapy is infrequently used to palliate dysphagia in some countries. To clarify the availability of palliative treatment for dysphagia from esophageal cancer and explain why brachytherapy is not routinely performed are unknown, this study investigated the use of brachytherapy and external beam radiotherapy for dysphagia from esophageal cancer. METHODS: Japanese Radiation Oncology Study Group members completed a survey and selected the treatment that they would recommend for hypothetical cases of dysphagia from esophageal cancer. RESULTS: Of the 136 invited facilities, 61 completed the survey (44.9%). Four (6.6%) facilities performed brachytherapy of the esophagus, whereas brachytherapy represented the first-line treatment at three (4.9%) facilities. Conversely, external beam radiotherapy alone and chemoradiotherapy were first-line treatments at 61 and 58 (95.1%) facilities, respectively. In facilities that performed brachytherapy, the main reason why brachytherapy of the esophagus was not performed was high invasiveness (30.2%). Definitive-dose chemoradiotherapy with (≥50 Gy) tended to be used in patients with expected long-term survival. CONCLUSIONS: Few facilities routinely considered brachytherapy for the treatment of dysphagia from esophageal cancer in Japan. Conversely, most facilities routinely considered external beam radiotherapy. In the future, it will be necessary to optimize external beam radiotherapy.

Pulmonary Apical Opacities on Thin-Section Computed Tomography: Relationship to Primary Spontaneous Pneumothorax in Young Male Patients and Corresponding Histopathologic Findings.

OBJECTIVE: The purpose of this study was to test the hypothesis that apical opacities on computed tomography (CT) are related to occurrence of primary spontaneous pneumothorax (PSP) in young male patients. METHODS: We compared the frequency of apical opacities on thin-section CT between 70 male patients with PSP (PSP group) and 74 male patients without a history of PSP (non-PSP group). We also evaluated histopathologic findings of 39 specimens from 37 surgical cases in the PSP group. RESULTS: Apical opacities were significantly more frequent in the PSP group than in the non-PSP group (right side, P = 0.01; left side, P = 0.005). Histopathologically, subpleural band-like alveolar collapse was seen in 35 specimens (89.7%), which was always accompanied by fibroelastosis and fibroblastic foci. CONCLUSIONS: Apical opacities on CT were significantly associated with PSP in young male patients. These apical opacities histopathologically correspond to fibrotic pleural thickening with subpleural alveolar collapse.

Present clinical practices of stereotactic irradiation for metastatic brain tumors in Japan: results of questionnaire survey of the Japanese Radiation Oncology Study Group (JROSG) working subgroup for neurological tumors.

BACKGROUND: To determine the current practice of stereotactic irradiation (STI) for brain metastases in Japan by a questionnaire survey. METHODS: A questionnaire was distributed to 313 institutions performing STI with one of the following machines: Gamma Knife (GK), CyberKnife (CK), Novalis (Nov), or other linear accelerator (LINAC)-based systems (OLS). The participation was voluntary. RESULTS: There were 163 responding institutions. The total number of STI treatments between April 2013 and March 2014 was 10,684. Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) were performed in 8624 (80.7%) and 2060 (19.3%) cases, respectively. Whole-brain radiation therapy (WBRT) was performed for a total of 3515 cases. For a case model of a 1.5-cm solitary brain metastasis in a non-eloquent area, the most common GTV-PTV margin was 2 mm (22 of 114 institutions), and an institutional standard fraction was 1 (75 of 114 institutions). The doses for the model case also varied from 13.0 to 26.0 Gy (Median 20 Gy) when converted to SRS (α/ß = 10). A prescription point was at the PTV margin the most. The median dose constraints which were converted to SRS (α/ß = 3) to organs at risk were 12.2, 12.7, and 13.7 Gy for optic nerves, cavernous sinus, and brainstem, respectively. CONCLUSIONS: STI for brain metastases in current practice varied significantly among institutions. These different strategies relied mostly on the type of treatment machine used. It is thus necessary to establish a common guideline to express dose prescriptions and plan qualities for different STI machines.

Japanese structure survey of radiation oncology in 2009 with special reference to designated cancer care hospitals.

BACKGROUND: The structure of radiation oncology in designated cancer care hospitals in Japan was surveyed in terms of equipment, personnel, patient load, and geographic distribution, and compared with the structure in other radiotherapy facilities and the previous survey. METHODS: The Japanese Society for Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2009. The structures of 365 designated cancer care hospitals and 335 other radiotherapy facilities were compared. RESULTS: Designated cancer care hospitals accounted for 50.0% of all the radiotherapy facilities in Japan. The patterns of equipment and personnel in designated cancer care hospitals and the other radiotherapy facilities were, respectively, as follows: linear accelerators per facility: 1.4 and 1.0; dual-energy function: 78.6 and 61.3%; three-dimensional conformal radiotherapy function: 88.5 and 70.0%; intensity-modulated radiotherapy function: 51.6 and 25.3%; annual number of patients per linear accelerator: 301.3 and 185.2; Ir-192 remote-controlled after-loading systems: 31.8 and 4.2%; and average number of full-time equivalent radiation oncologists per facility: 1.8 and 0.8. Compared with the previous survey, the ownership ratio of equipment and personnel improved in both designated cancer care hospitals and the other radiotherapy facilities. Annual patient loads per full-time equivalent radiation oncologist in the designated cancer care hospitals and the other radiotherapy facilities were 225.5 and 247.6, respectively. These values exceeded the standard guidelines level of 200. CONCLUSIONS: The structure of radiation oncology in designated Japanese cancer care hospitals was more mature than that in the other radiotherapy facilities. There is still a shortage of personnel. The serious understaffing problem in radiation oncology should be corrected in the future.

Pulmonary focal fibrosis associated with microscopic arterio-venous fistula manifesting as focal ground-glass opacity on thin-section CT.

BACKGROUND: Focal ground-glass opacity (GGO) on thin-section computed tomography (CT) may be seen in atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ that has recently been renamed from bronchioloalveolar carcinoma (BAC) and various benign conditions. CASE PRESENTATION: We report a case of pulmonary focal fibrosis associated with microscopic arterio-venous fistula (AVF), which showed a focal area of GGO on thin-section CT. The patient was a 58-year-old woman with a GGO on thin-section CT which had increased in size over the period of 2 years. Slightly dilated vessels and thickened interlobular septa were also noted around the GGO. It was diagnosed preoperatively as adenocarcinoma in situ and a partial lung resection by video-assisted thoracic surgery (VATS) was performed. Pathological examination yielded a diagnosis of focal fibrosis associated with microscopic AVF. CONCLUSION: We speculate that the focal fibrosis was produced by a prolonged congestion due to the AVF and that the dilated vessels and thickening of interlobular septa on thin-section CT related to the AVF. Microscopic AVF may be one of the etiologies of focal fibrosis showing focal GGO on thins-section CT. Dilated vessels and thickened interlobular septa around the GGO might offer a clue to the diagnosis of this disease entity. In addition, it should be noted that focal fibrosis may increase in size.

The influence of image reconstruction methods on the diagnosis of pulmonary emphysema with convolutional neural network.

This study investigated the influence of iterative reconstruction (IR) methods on computed tomography (CT) images when training convolutional neural network (CNN) models to diagnose pulmonary emphysema. To evaluate the influence of the IR algorithm on CNN, the present study comprised two steps: the comparison of noise reduction by IR algorithms using phantom examinations and the change in performance of CNN with IR algorithms using patient data. We retrospectively analyzed 97 patients. Raw CT data were reconstructed using the filtered back-projection (FBP) and adaptive statistical iterative reconstruction V (ASIR-V) algorithms with blending levels of 30%, 50%, and 70%. The models were trained using reconstructed CT images and were named the FBP, ASIR-V30, ASIR-V50, and ASIR-V70 models. The mean and the standard deviation of the CT values were 11.3 ± 21.2 at FBP, 11.0 ± 17.3 at ASIR-V30, 11.0 ± 14.4 at ASIR-V50, and 11.0 ± 11.8 at ASIR-V70. For all the evaluation metrics, the best values were obtained with the FBP model applied to the ASIR-V70 test images. The worst values were obtained with the ASIR-V70 model applied to the FBP test images. The model trained with FBP images exhibited significantly better performance than the models trained using IR images. The reduction in image noise with the IR algorithm on the test images contributed to improving the accuracy of the classification of emphysema subtypes using CNN.

Japanese structure survey of radiation oncology in 2007 with special reference to designated cancer care hospitals.

BACKGROUND AND PURPOSE: The structure of radiation oncology in designated cancer care hospitals in Japan was investigated in terms of equipment, personnel, patient load, and geographic distribution. The effect of changes in the health care policy in Japan on radiotherapy structure was also examined. MATERIAL AND METHODS: The Japanese Society of Therapeutic Radiology and Oncology surveyed the national structure of radiation oncology in 2007. The structures of 349 designated cancer care hospitals and 372 other radiotherapy facilities were compared. RESULTS: Respective findings for equipment and personnel at designated cancer care hospitals and other facilities included the following: linear accelerators/facility: 1.3 and 1.0; annual patients/linear accelerator: 296.5 and 175.0; and annual patient load/full-time equivalent radiation oncologist was 237.0 and 273.3, respectively. Geographically, the number of designated cancer care hospitals was associated with population size. CONCLUSION: The structure of radiation oncology in Japan in terms of equipment, especially for designated cancer care hospitals, was as mature as that in European countries and the United States, even though the medical costs in relation to GDP in Japan are lower. There is still a shortage of manpower. The survey data proved to be important to fully understand the radiation oncology medical care system in Japan.

Evaluation of a Monte Carlo-based algorithm for the influence of totally implantable venous access ports in external radiation therapy.

PURPOSE: This study aimed to assess whether a Monte Carlo (MC)-based algorithm reflects the influence of totally implantable venous access ports (TIVAPs) in external radiation therapy. MATERIALS AND METHODS: The present study comprised two steps: experimental measurements of depth doses and surface doses with and without TIVAPs and calculation with an MC-based algorithm. RESULTS: The TIVAP-associated maximum dose reduction compared with the dose at the same depths without TIVAPs was 7.8% at 4 MV, 6.9% at 6 MV, and 5.7% at 10 MV in measurement, and 7.4% at 4 MV, 6.6% at 6 MV, and 5.5% at 10 MV in calculation. Relative surface doses were higher with TIVAPs made of titanium, due to a higher fluence of backscattered electrons from the TIVAPs, than with plastic TIVAPs. There were no significant differences in the relative differences between the measured and calculated doses of the titanium TIVAP group and the plastic TIVAP group at 4 MV (p = 0.99), 6 MV (p = 0.67), and 10 MV (p = 0.54). CONCLUSION: TIVAPs caused target dose reductions and dose increase near the TIVAP, especially when made of titanium. The influences are reflected in the MC-based algorithm.

Practice patterns for postoperative radiation therapy in patients with metastases to the long bones: a survey of the Japanese Radiation Oncology Study Group.

Evidence regarding postoperative radiation therapy (PORT) for metastases to the long bones is lacking. Characterizing the current practice patterns and identifying factors that influence dose-fractionation schedules are essential for future clinical trials. An internet-based survey of the palliative RT subgroup of the Japanese Radiation Oncology Study Group was performed in 2017 to collect data regarding PORT prescription practices and dose-fractionation schedules. Responders were also asked to recommend dose-fractionation schedules for four hypothetical cases that involved a patient with impending pathological fractures and one of four clinical features (poor prognosis, solitary metastasis, radio-resistant primary tumor or expected long-term survival). Responders were asked to indicate their preferred irradiation fields and the reasons for the dose fractionation schedule they chose. Responses were obtained from 89 radiation oncologists (67 institutions and 151 RT plans) who used 22 dose-fractionation schedules, with the most commonly used and recommended schedule being 30 Gy in 10 fractions. Local control was the most common reason for preferring longer-course RT. High-dose fractionated schedules were preferred for oligometastasis, and low-dose regimens were preferred for patients with a poor prognosis; however, single-fraction RT was not preferred. Most respondents recommended targeting the entire orthopedic prosthesis. These results indicated that PORT using 30 Gy in 10 fractions to the entire orthopedic prosthesis is preferred in current Japanese practice and that single-fraction RT was not preferred. Oligometastasis and poor prognosis influenced the selection of high- or low-dose regimens.

Japanese structure survey of radiation oncology in 2012.

This paper describes the ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution to identify and overcome any existing limitations. From March 2013 to August 2016, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2012. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 213 000 and 251 000, respectively. Additionally, the estimated cancer incidence was 865 238 cases with ~24.6% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 864), telecobalt (n = 0), Gamma Knife (n = 44), 60Co remote afterloading system (RALS; n = 23) and 192Ir RALS (n = 130). The LINAC system used dual-energy functions in 651 units, 3D conformal radiotherapy functions in 759 and intensity-modulated radiotherapy (IMRT) functions in 466. There were 792 Japan Radiological Society/Japanese Society for Radiation Oncology-certified radiation oncologists, 1061.6 full-time equivalent (FTE) radiation oncologists, 2124.2 FTE radiotherapy technologists, 181.3 FTE medical physicists, 170.9 FTE radiotherapy quality managers and 841.5 FTE nurses. The frequency of IMRT use significantly increased during this time. In conclusion, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility although there was a shortage of personnel in 2012.

Japanese Structure Survey of Radiation Oncology in 2011.

We evaluated the evolving structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution to identify and overcome any existing limitations. From March 2012 to August 2015, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2011. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 211 000 and 250 000, respectively. Additionally, the estimated cancer incidence was 851 537 cases with approximately 24.8% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 836), telecobalt (n = 3), Gamma Knife (n = 46), 60Co remote afterloading system (RALS; n = 24), and 192Ir RALS (n = 125). The LINAC system used dual-energy functions in 619 units, 3D conformal radiotherapy functions in 719 and intensity-modulated radiotherapy (IMRT) functions in 412. There were 756 JRS or JASTRO-certified radiation oncologists, 1018.5 full-time equivalent (FTE) radiation oncologists, 2026.7 FTE radiotherapy technologists, 149.1 FTE medical physicists, 141.5 FTE radiotherapy quality managers and 716.3 FTE nurses. The frequency of IMRT use significantly increased during this time. To conclude, although there was a shortage of personnel in 2011, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility.

Japanese structure survey of radiation oncology in 2010.

We evaluated the evolving structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and overcome any existing limitations. From March 2011 to June 2013, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2010. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 211 000 and 251 000, respectively. Additionally, the estimated cancer incidence was 805 236 cases, with ~26.2% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 829), telecobalt (n = 9), Gamma Knife (n = 46), 60Co remote afterloading system (RALS; n = 28), and 192Ir RALS (n = 131). The LINAC system used dual-energy functions in 586 units, three-dimensional conformal radiotherapy functions in 663, and intensity-modulated radiotherapy (IMRT) functions in 337. There were 564 JASTRO-certified radiation oncologists, 959.2 full-time equivalent (FTE) radiation oncologists, 1841.3 FTE radiotherapy technologists, 131.3 FTE medical physicists, 121.5 FTE radiotherapy quality managers, and 649.6 FTE nurses. The frequency of IMRT use significantly increased during this year. To conclude, although there was a shortage of personnel in 2010, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility.

The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations.

BACKGROUND: Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage is poorly understood. METHODS: We performed a retrospective observational study of 500 patients with malformations who were treated with radiosurgery with use of a gamma knife. The rates of hemorrhage were assessed during three periods: before radiosurgery, between radiosurgery and the angiographic documentation of obliteration of the malformation (latency period), and after angiographic obliteration. RESULTS: Forty-two hemorrhages were documented before radiosurgery (median follow-up, 0.4 year), 23 during the latency period (median follow-up, 2.0 years), and 6 after obliteration (median follow-up, 5.4 years). As compared with the period between diagnosis and radiosurgery, the risk of hemorrhage decreased by 54 percent during the latency period (hazard ratio, 0.46; 95 percent confidence interval, 0.26 to 0.80; P=0.006) and by 88 percent after obliteration (hazard ratio, 0.12; 95 percent confidence interval, 0.05 to 0.29; P<0.001). The risk was significantly reduced during the period after obliteration, as compared with the latency period (hazard ratio, 0.26; 95 percent confidence interval, 0.10 to 0.68; P=0.006). The reduction was greater among patients who presented with hemorrhage than among those without hemorrhage at presentation and similar in analyses that took into account the delay in confirming obliteration by means of angiography and analyses that excluded data obtained during the first year after diagnosis. CONCLUSIONS: Radiosurgery significantly decreases the risk of hemorrhage in patients with cerebral arteriovenous malformations, even before there is angiographic evidence of obliteration. The risk of hemorrhage is further reduced, although not eliminated, after obliteration.

Tolerance of pyramidal tract to gamma knife radiosurgery based on diffusion-tensor tractography.

PURPOSE: To minimize the morbidity of radiosurgery for critically located lesions, we integrated diffusion-tensor tractography into treatment planning for gamma-knife radiosurgery. We calculated the refined tolerance of the pyramidal tract (PT) after prospective application of the technique to additional patients. METHODS AND MATERIALS: The relationship between the dosimetry during treatment planning and the development of subsequent motor complications was investigated in 24 patients, 9 studied retrospectively and 15 studied prospectively. The maximal dose to the PT and the volumes of the PT that received > or = 20 Gy (20-Gy volume) and > or = 25 Gy (25-Gy volume) were calculated. Univariate logistic regression analyses were used to produce dose-response curves. Differences in the tolerable dose according to the PT location were calculated. RESULTS: Univariate logistic regression analysis of the motor complications revealed a significant independent correlation with the maximal dose to the PT and the 20- and 25-Gy volumes. The maximal dose to the PT with a 5% risk of motor complications was 23 Gy compared with 15 Gy in our previous report. The risk of motor complications was significantly greater in the internal capsule than in the corona radiata for the 20- and 25-Gy volumes in generalized Wilcoxon tests (p = 0.031), although no significant difference was observed for the maximal dose. CONCLUSION: The tolerable dose of the PT was greater than that previously reported. The internal capsule was more sensitive to high-dose irradiation over a wide area of the PT, probably owing to the dense concentration of motor fibers.

Japanese structure survey of radiation oncology in 2005 based on institutional stratification of patterns of care study.

PURPOSE: To evaluate the structure of radiation oncology in Japan in terms of equipment, personnel, patient load, and geographic distribution to identify and improve any deficiencies. METHODS AND MATERIALS: A questionnaire-based national structure survey was conducted between March 2006 and February 2007 by the Japanese Society of Therapeutic Radiology and Oncology. These data were analyzed in terms of the institutional stratification of the Patterns of Care Study. RESULTS: The total numbers of new cancer patients and total cancer patients (new and repeat) treated with radiotherapy in 2005 were estimated at approximately 162,000 and 198,000, respectively. In actual use were 765 linear accelerators, 11 telecobalt machines, 48 GammaKnife machines, 64 60Co remote-controlled after-loading systems, and 119 192Ir remote-controlled after-loading systems. The linear accelerator systems used dual-energy function in 498 systems (65%), three-dimensional conformal radiotherapy in 462 (60%), and intensity-modulated radiotherapy in 170 (22%). There were 426 Japanese Society of Therapeutic Radiology and Oncology-certified radiation oncologists, 774 full-time equivalent radiation oncologists, 117 medical physicists, and 1,635 radiation therapists. Geographically, a significant variation was found in the use of radiotherapy, from 0.9 to 2.1 patients/1,000 population. The annual patient load/FTE radiation oncologist was 247, exceeding the Blue Book guidelines level. Patterns of Care Study stratification can clearly discriminate the maturity of structures according to their academic nature and caseload. CONCLUSIONS: The Japanese structure has clearly improved during the past 15 years in terms of equipment and its use, although the shortage of manpower and variations in maturity disclosed by this Patterns of Care Study stratification remain problematic. These constitute the targets for nationwide improvement in quality assurance and quality control.

Preoperative radiation response evaluated by 18-fluorodeoxyglucose positron emission tomography predicts survival in locally advanced rectal cancer.

PURPOSE: This study focuses on the prognostic survival value of postirradiation metabolic activity in primary rectal cancer as measured with 18-fluorodeoxyglucose positron emission tomography. METHODS: From July 1995 to March 2002, all 59 patients underwent two series of fluorodeoxyglucose positron emission tomography: one before preoperative radiation (standardized uptake values-1), and the other two to three weeks after radiation (standardized uptake values-2). Standardized uptake values-1 and standardized uptake values-2 correspond to before and after radiation, respectively. RESULTS: In univariate analysis, the following emerged as significant prognostic variables: with or without residual tumor, pathologic differentiation, with or without recurrence, standardized uptake values-2, and with or without lymph node metastases. In multivariate analysis, residual tumor and standardized uptake values-2 were significant prognostic factors for survival. The median survival and the five-year overall survival rate comparing standardized uptake values-2 values <5 vs. >5 were 95 vs. 42 months and 70 vs. 44 percent, respectively (P = 0.042). CONCLUSION: A significant survival benefit was observed in patients with low fluorodeoxyglucose uptake after preoperative radiotherapy in primary tumors of rectal cancer.

Optimal timing for Gamma Knife surgery after hemorrhage from brain arteriovenous malformations.

OBJECT: Optimal timing of Gamma Knife surgery (GKS) after hemorrhage from brain arteriovenous malformations (AVMs) is unclear and of concern to neurosurgeons because GKS is usually performed after absorption of the hematoma. The authors investigated whether waiting for hematoma absorption is beneficial and aimed to clarify the optimal treatment timing. METHODS: The authors retrospectively studied 211 patients with AVMs who presented with hemorrhage and underwent GKS as the initial treatment. Patients were categorized into 3 groups according to the interval between the time of first hemorrhage and GKS, as follows: Group 1, 0-3 months (70 patients); Group 2, 3-6 months (62 patients); and Group 3, > 6 months (79 patients). The obliteration rates, number of hemorrhages before and after GKS, and complication rates were compared between these 3 groups. The authors also analyzed a subgroup of 127 patients who presented with intracerebral hemorrhage (ICH) to identify the influence of ICH on outcome. RESULTS: After a median follow-up of 6.3 years, the rates of obliteration, hemorrhage after treatment, and complication were not significantly different between the 3 groups even though the patients with a longer interval before GKS (Group 3) had more AVMs in eloquent areas and neurological deficits. However, the numbers of patients with preoperative hemorrhage in the interval before GKS was significantly higher in Group 3 (1, 3, and 20 patients in Group 1, 2, and 3, respectively). These results were similar in the analyses of 127 patients presenting with ICH. CONCLUSIONS: No benefit was detected in waiting for hematoma absorption until GKS after hemorrhage from AVM. Because of higher hemorrhagic risk until GKS > 6 months after hemorrhage, the authors recommend GKS within 6 months after hemorrhage.

Cyst formation after stereotactic radiosurgery for intracranial meningioma.

The authors report 2 cases of delayed cyst formation after gamma knife radiosurgery for 3 meningioma lesions. All 3 lesions reported here had a distinctive feature before gamma knife treatment of small and spotty intratumoral cysts. One patient experienced an intriguing clinical course of spontaneous regression of the enlarged cyst, and 2 of the 3 lesions became symptomatic requiring surgical interventions. Cyst formation as a postradiosurgical complication is relatively rare in meningioma patients in the literature, and its pathogenesis is unclear. We describe herein the clinical courses of these 2 patients and review the relevant literature in this report. From our experience of these 2 cases, we suggest that we should be aware of the possible development of spotty intratumoral cysts into larger cysts after stereotactic radiosurgery and that we should carefully observe such patients after the treatment.

Effects of Surgery With Salvage Stereotactic Radiosurgery Versus Surgery With Whole-Brain Radiation Therapy in Patients With One to Four Brain Metastases (JCOG0504): A Phase III, Noninferiority, Randomized Controlled Trial.

Purpose Whereas whole-brain radiotherapy (WBRT) has been the standard treatment of brain metastases (BMs), stereotactic radiosurgery (SRS) is increasingly preferred to avoid cognitive dysfunction; however, it has not been clearly determined whether treatment with SRS is as effective as that with WBRT or WBRT plus SRS. We thus assessed the noninferiority of salvage SRS to WBRT in patients with BMs. Patients and Methods Patients age 20 to 79 years old with performance status scores of 0 to 2-and 3 if caused only by neurologic deficits-and with four or fewer surgically resected BMs with only one lesion > 3 cm in diameter were eligible. Patients were randomly assigned to WBRT or salvage SRS arms within 21 days of surgery. The primary end point was overall survival. A one-sided α of .05 was used. Results Between January 2006 and May 2014, 137 and 134 patients were enrolled in the WBRT and salvage SRS arms, respectively. Median overall survival was 15.6 months in both arms (hazard ratio, 1.05; 90% CI, 0.83 to 1.33; one-sided P for noninferiority = .027). Median intracranial progression-free survival of patients in the WBRT arm (10.4 months) was longer than that of patients in the salvage SRS arm (4.0 months). The proportions of patients whose Mini-Mental Status Examination and performance status scores that did not worsen at 12 months were similar in both arms; however, 16.4% of patients in the WBRT arm experienced grade 2 to 4 cognitive dysfunction after 91 days postenrollment, whereas only 7.7% of those in the SRS arm did ( P = .048). Conclusion Salvage SRS is noninferior to WBRT and can be established as a standard therapy for patients with four or fewer BMs.

Neurocognitive function of patients with brain metastasis who received either whole brain radiotherapy plus stereotactic radiosurgery or radiosurgery alone.

PURPOSE: To determine how the omission of whole brain radiotherapy (WBRT) affects the neurocognitive function of patients with one to four brain metastases who have been treated with stereotactic radiosurgery (SRS). METHODS AND MATERIALS: In a prospective randomized trial between WBRT+SRS and SRS alone for patients with one to four brain metastases, we assessed the neurocognitive function using the Mini-Mental State Examination (MMSE). Of the 132 enrolled patients, MMSE scores were available for 110. RESULTS: In the baseline MMSE analyses, statistically significant differences were observed for total tumor volume, extent of tumor edema, age, and Karnofsky performance status. Of the 92 patients who underwent the follow-up MMSE, 39 had a baseline MMSE score of < or =27 (17 in the WBRT+SRS group and 22 in the SRS-alone group). Improvements of > or =3 points in the MMSEs of 9 WBRT+SRS patients and 11 SRS-alone patients (p = 0.85) were observed. Of the 82 patients with a baseline MMSE score of > or =27 or whose baseline MMSE score was < or =26 but had improved to > or =27 after the initial brain treatment, the 12-, 24-, and 36-month actuarial free rate of the 3-point drop in the MMSE was 76.1%, 68.5%, and 14.7% in the WBRT+SRS group and 59.3%, 51.9%, and 51.9% in the SRS-alone group, respectively. The average duration until deterioration was 16.5 months in the WBRT+SRS group and 7.6 months in the SRS-alone group (p = 0.05). CONCLUSION: The results of the present study have revealed that, for most brain metastatic patients, control of the brain tumor is the most important factor for stabilizing neurocognitive function. However, the long-term adverse effects of WBRT on neurocognitive function might not be negligible.