Synchronous glioblastoma and brain metastases: illustrative case.

BACKGROUND: Radiosurgical treatment of brain metastases is usually performed without brain tissue confirmation. While it is extremely rare for glioblastoma to develop concurrently in patients with brain metastases, they can look radiographically similar, and recognition is important because it alters management and prognosis. The synchronous presence of brain metastases and glioblastoma has not been published to date in the literature, making this a rare illustrative case. OBSERVATIONS: A 70-year-old female had lung biopsy-proven metastatic lung adenocarcinoma and multiple brain metastases. Her treatment course included initial carboplatin, pemetrexed, and bevacizumab followed by maintenance nivolumab, and she underwent stereotactic radiosurgery to the multiple brain metastases. During interval radiological surveillance, one lesion in the right temporal lobe was noted to slowly progress associated with development of significant perilesional edema causing midline shift despite repeated stereotactic radiosurgical treatments. Biopsy of this lesion revealed glioblastoma, IDH wildtype. LESSONS: Glioblastomas and brain metastases have similar radiological features, so the possibility of incorrect diagnosis needs to be considered for all lesions with interval growth poststereotactic radiosurgery. Biopsy and/or resection/laser ablation should be considered prior to reirradiation.

Radiotherapy for Brain Metastases from Thyroid Cancer: An Institutional and National Retrospective Cohort Study.

Background: Stereotactic radiosurgery (SRS) is the standard of care for patients with a limited number of brain metastases. Despite the fact that the seminal studies regarding SRS for brain metastases were largely tissue agnostic, several current national guidelines do not uniformly recommend SRS in thyroid cancer. We therefore investigated oncological outcomes in a cohort of patients with brain metastases from thyroid cancer who received radiotherapy (RT) at our institution as well as those in a nationally representative cancer cohort, the National Cancer Database (NCDB). Materials and Methods: We identified patients with thyroid cancer and brain metastases treated with RT at our institution from 2002 through 2020. For the NCDB cohort, the national database of patients with thyroid cancer was screened on the basis of brain-directed RT or brain metastases. For the institutional cohort, the cumulative risk of local failure (LF), distant intracranial failure, and radiation necrosis were calculated, adjusted for the competing risk of death. Overall survival (OS) in both cohorts was analyzed using the Kaplan-Meier method. Univariate analysis was accomplished via clustered competing risks regression. Results: For the institutional cohort, we identified 33 patients with 212 treated brain metastases. OS was 6.6 months. The 1-year cumulative incidences of LF and distant intracranial failures were 7.0% and 38%, respectively. The 1-year risk of radiation necrosis was 3.3%. In the NCDB cohort, there were 289 patients, and the median survival was 10.2 months. NCDB national practice patterns analysis showed an increasing use of SRS over time in both the entire cohort and the subset of anaplastic patients. Univariate analysis was performed for OS, risk of LF, risk of regional intracranial failure, and risk of radiation necrosis. Conclusions: SRS is a safe, effective, and increasingly utilized treatment for thyroid cancer brain metastases of any histology and should be the standard of care treatment.

The Stanford stereotactic radiosurgery experience on 7000 patients over 2 decades (1999-2018): looking far beyond the scalpel.

OBJECTIVE: The CyberKnife (CK) has emerged as an effective frameless and noninvasive method for treating a myriad of neurosurgical conditions. Here, the authors conducted an extensive retrospective analysis and review of the literature to elucidate the trend for CK use in the management paradigm for common neurosurgical diseases at their institution. METHODS: A literature review (January 1990-June 2019) and clinical review (January 1999-December 2018) were performed using, respectively, online research databases and the Stanford Research Repository of patients with intracranial and spinal lesions treated with CK at Stanford. For each disease considered, the coefficient of determination (r2) was estimated as a measure of CK utilization over time. A change in treatment modality was assessed using a t-test, with statistical significance assessed at the 0.05 alpha level. RESULTS: In over 7000 patients treated with CK for various brain and spinal lesions over the past 20 years, a positive linear trend (r2 = 0.80) in the system's use was observed. CK gained prominence in the management of intracranial and spinal arteriovenous malformations (AVMs; r2 = 0.89 and 0.95, respectively); brain and spine metastases (r2 = 0.97 and 0.79, respectively); benign tumors such as meningioma (r2 = 0.85), vestibular schwannoma (r2 = 0.76), and glomus jugulare tumor (r2 = 0.89); glioblastoma (r2 = 0.54); and trigeminal neuralgia (r2 = 0.81). A statistically significant difference in the change in treatment modality to CK was observed in the management of intracranial and spinal AVMs (p < 0.05), and while the treatment of brain and spine metastases, meningioma, and glioblastoma trended toward the use of CK, the change in treatment modality for these lesions was not statistically significant. CONCLUSIONS: Evidence suggests the robust use of CK for treating a wide range of neurological conditions.

Esophageal variceal hemorrhage: the role of MDCT characteristics in predicting the presence of varices and bleeding risk.

PURPOSE: To investigate the associated Multi-Detector Computed Tomography (MDCT) features for esophageal varices (EVs) and esophageal variceal hemorrhage (EVH), with particular emphasis on different collateral veins. MATERIALS AND METHODS: All cirrhotic patients who had undergone both Upper Gastrointestinal Tract (UGIT) endoscopy and contrast-enhanced MDCT within 6 months from 2013 to 2019 were included in the study. MDCT of 124 patients, 76 males and 48 females, aged between 21 and 73 years old were evaluated for presence of EV and presence and size of different collaterals. The presence and size of collaterals in patients with high-risk EVs or EVH were compared with others. RESULTS: Findings of EV in MDCT analysis were the best predictor of EV or EVH, and presence (and/or size) of following collaterals showed a significant relationship with both EV and EVH: coronary (p = 0.006, 0.002), short gastric (SGC) (p = 0.02, < 0.001), and paraesophageal (p = 0.04, 0.01). Those presenting each aforementioned collaterals or with higher collateral size were more likely to develop the EV or EVH. Yet, other collaterals indicated no similar association: para-umbilical, omental, perisplenic, and splenorenal. Main coronary vein (p = 0.02, 0.03) and fundus (p = 0.006, 0.001) varices' sizes were also significantly higher in patients with EV or EVH. Finally, we suggested an imaging-based model (presence of SGC, SGC size > 2.5 mm, presence of EV, and coronary vein size > 3.5 mm) with 75.86% sensitivity, 76.92% specificity, and 76.36% accuracy to predict the presence of EVs according to UGIT endoscopy. Furthermore, we presented another model (presence of SGC, SGC size > 2.5 mm, presence of EV, and MELD score > 11.5 mm) to predict the occurrence of EVH with 75.86% sensitivity, 76.92% specificity, and 76.36% accuracy. CONCLUSION: We suggested imaging characteristics for predicting EV and EVH with especial emphasis on the presence and size of various collaterals; then, we recommended reliable imaging criteria with high specificity and accuracy for predicting the EV and EVH.