The Role of Adjuvant Radiotherapy After Gross Total Resection of Atypical Meningiomas

Atypical meningiomas (AMs) frequently recur after gross total resection (GTR). We conducted a meta-analysis to evaluate the benefit of adjuvant therapy after GTR of AMs. A PubMed/MEDLINE search identified studies detailing AMs treated by GTR alone or GTR and adjuvant radiotherapy (RT) published between 1984 and 2012. Original data from 14 retrospective studies were combined and analyzed. Odds ratio (OR) and χ2 testing were used when appropriate. Selected datasets were used to generate each variable, where available. A total of 757 patients (male/female ratio 9:10) with AMs were included; 72.52% (n = 549) of AMs were treated by GTR alone, and 27.47% (n = 208) underwent adjuvant RT after GTR to a median dose of 54 Gy. The crude recurrence rate was twice as high without adjuvant RT (33.7% vs. 15%, P = 0.005). The 1-year local control rate was 90% for GTR and 97% for GTR + RT (OR = 3.36, P = 0.11). The median 5-year local control rate was 62% for GTR and 73% for GTR + RT, respectively (OR = 1.71, P = 0.06). The 5-year overall survival for each group was 90% (OR = 0.97, P = 0.95). A total of 85% of recurrences were salvaged, 33% by RT and 67% by surgery. Radiation-related toxicity was <10%, at a median follow-up of 42 months. Postoperative RT for AMs may decrease risk for relapse of disease and improve local control, although most tumors are salvageable with surgery or radiation. Although the data suggest little or no impact of postoperative RT on survival, further investigation regarding the long-term efficacy and toxicity of radiation is warranted

The role of whole-brain radiation therapy after stereotactic radiation surgery for brain metastases.

The benefit of whole-brain radiation therapy (WBRT) following stereotactic radiation surgery (SRS) for brain metastases is controversial. We conducted a systematic analysis of published literature to explore the outcome of brain metastases treated with SRS and WBRT versus SRS alone using PubMed and MEDLINE. Outcomes including survival, control, salvage therapy, and other quality of life measures were reported. Three randomized controlled trials involving 389 patients with 1 to 4 brain metastases were selected. In 2 of these trials (n = 190), the mean 1-year survival was 33.2% for SRS + WBRT and 38.7% for SRS alone (P = .5233); 1-year local control was 89% for SRS + WBRT and 71% for SRS alone (P \u3c .001). Mean crude distant recurrence rate for SRS + WBRT was 36.6% and 54% for SRS alone (P \u3c .001). Patients without WBRT were over 3 times more likely to require salvage therapy (P \u3c .001). The addition of WBRT was associated with a decreased health-related quality of life assessment, mini mental status exam, and Hopkins Verbal Learning Test (P \u3c .05). Five retrospective studies (n = 1122) were also included in a separate analysis and yielded findings that supported results from the randomized trials. Our systematic analysis demonstrates that adjuvant WBRT following SRS for the treatment of oligometastases in the brain is more effective at controlling local and distant recurrence than SRS alone, but there is no apparent benefit for survival or symptomology. The proven cognitive decline and neurotoxicity present with WBRT should be weighed against the benefit of local control. Prognosis of brain metastasis is poor regardless of current treatment and further exploration for alternative adjuvant treatment for SRS is warranted

The role of 5-aminolevulinic acid in brain tumor surgery: a systematic review

Recently, 5-aminolevulinic acid (5-ALA) has been utilized as an adjuvant to the surgical resection of primary brain tumors and metastases. We conducted a systematic review of the literature to further understand the role of 5-ALA in neurosurgery. Our goal was to identify the utility of 5-ALA during resection by evaluating its sensitivity and specificity for different tumor types, as well as the extent of tumor resection achieved while using 5-ALA. A search of the literature was conducted using the PubMed database for the period January 1990 through May 2014. Surgical series in which 5-ALA was used for brain neoplasm resections were evaluated for tumor histology, sensitivity, specificity, extent of resection, complications, and outcomes. Twenty-two series, involving 1163 patients, were included in our review. 5-ALA sensitivity was highest in high-grade gliomas (85 %) and meningiomas (81 %). 5-ALA specificity was high in meningiomas (100 %), as well as metastases (84 %) and high-grade gliomas (82 %). Gross total resection (GTR) was achieved using 5-ALA in 66.2 % of all gliomas and 69.6 % of meningiomas, regardless of histological subtype. 5-ALA may be a useful tool in increasing the extent of resection and achieving GTR in intracranial tumors. The resection of tumors for which 5-ALA has high sensitivity and specificity, such as high-grade gliomas, may lead to an increase in extent of resection when compared to operations using only standard white light. Further evidence for the use of 5-ALA in meningiomas and certain subtypes of metastases may be needed to qualify its efficacy

Ibrutinib in Refractory or Relapsing Primary Central Nervous System Lymphoma: A Systematic Review

Primary Central Nervous System Lymphoma (PCNSL) is a rare variant of Non-Hodgkin Lymphoma (NHL) representing 1-2% of all NHL cases. PCNSL is defined as a lymphoma that occurs in the brain, spinal cord, leptomeninges, or eyes. Efforts to treat PCNSL by traditional chemotherapy and radiotherapy have generally been unsuccessful as a significant proportion of patients have frequent relapses or are refractory to treatment. The prognosis of patients with Refractory or Relapsed (R/R) PCNSL is abysmal. The optimal treatment for R/R PCNSL is poorly defined as there are only a limited number of studies in this setting. Several studies have recently shown that ibrutinib, a Bruton tyrosine kinase (BTK) inhibitor, has promising results in the treatment of R/R PCNSL. However, these are preliminary studies with a limited sample size. In this systematic review, we explored and critically appraised the evidence about the efficacy of the novel agent ibrutinib in treating R/R PCNSL