Stereotactic radiosurgery for the treatment of recurrent high-grade gliomas: long-term follow-up

High-grade gliomas (HGG) are the most frequent primary central nervous system tumors; treatment of HCGs includes surgery and post-operative conformal radiotherapy associated with temozolomide (TMZ or procarbazine/lomustine/vincristine [PCV], specifically in patients with anaplastic oligodendrogliomas or anaplastic oligoastrocytomas). However, recurrence is common. Re-irradiation has been utilized in this setting for years and remains a feasible option, although there is always a concern regarding toxicity. Modern high-precision conformal techniques, including stereotactic radiosurgery (SRS), could improve the therapeutic ratio by delivering high biologically equivalent doses while reducing high-dose radiotherapy (RT) to normal brain tissue. In this paper, we present the results obtained after prolonged follow-up in patients who underwent SRS as a treatment for recurrent high-grade gliomas at San Francisco Hospital in Madrid, Spain

Stereotactic radiosurgery for the treatment of recurrent high-grade gliomas: long-term follow-up

High-grade gliomas (HGG) are the most frequent primary central nervous system tumors; treatment of HCGs includes surgery and post-operative conformal radiotherapy associated with temozolomide (TMZ or procarbazine/lomustine/vincristine [PCV], specifically in patients with anaplastic oligodendrogliomas or anaplastic oligoastrocytomas). However, recurrence is common. Re-irradiation has been utilized in this setting for years and remains a feasible option, although there is always a concern regarding toxicity. Modern high-precision conformal techniques, including stereotactic radiosurgery (SRS), could improve the therapeutic ratio by delivering high biologically equivalent doses while reducing high-dose radiotherapy (RT) to normal brain tissue. In this paper, we present the results obtained after prolonged follow-up in patients who underwent SRS as a treatment for recurrent high-grade gliomas at San Francisco Hospital in Madrid, Spain

Radionecrosis gigante recurrente imitando un glioma de alto grado: uso de ácido 5-aminolevulínico como técnica para su diferenciación.​

La radionecrosis (RN) es un efecto secundario de la radioterapia (RT) que afecta principalmente a la sustancia blanca y puede aparecer desde pocas semanas hasta varios años después de haber finalizado el tratamiento1,2. Tiene una incidencia del 3-9%, que aumenta a medida que mejora la supervivencia tras la RT. Se acepta que unas dosis <60 Gy en fracciones diarias de 2 Gy son seguras y tienen una incidencia menor del 5%, siendo éste el protocolo habitual para los gliomas de alto grado (STUPP)1-4. Histopatológicamente se observa necrosis vascular fibrinoide y daño endotelial que produce un aumento de permeabilidad capilar y ocasiona edema cerebral. Asimismo, se conoce el daño directo que tiene sobre las células gliales debido a su alta sensibilidad, produciendo desmielinización y necrosis directa. Una nueva teoría señala el efecto de respuesta inmunitaria del huésped a partir de citocinas inflamatorias1-3,5,6. El principal problema consiste en diferenciar la RN de la progresión tumoral, ya que ambas entidades presentan imágenes y características clínicas similares, como focalidad neurológica, así como edema y captación de contraste en el lecho tumoral. Los estudios diagnósticos, como resonancia magnética (RMi) de perfusión y espectroscopia, PET-TAC con FDG, muchas veces nos confunden con falsos positivos o falsos negativos, lo que hace que nos planteemos la intervención quirúrgica no sólo para eliminar el efecto de masa y mejorar la calidad de vida del paciente, sino también para establecer un diagnóstico claro. El método diagnóstico de elección, según varios autores, es la resección quirúrgica y la evaluación histopatológica, siempre y cuando las condiciones de los pacientes lo permitan1-4,7. Aunque la necrosis postirradiación (con una dosis alta) es un efecto secundario de la RT bien conocido, tanto en la bibliografía consultada como en nuestra propia experiencia pocas veces hemos visto RN tan severas, repetidas, que recurran en tan poco tiempo y que requieran tantas intervenciones terapéuticas como la RN del caso clínico que presentamos aquí. El uso de ácido 5-aminolevulínico (5-ALA) en estos casos es una herramienta útil y eficaz, intraoperatoria, que nos ayuda a tomar decisiones in situ y a replantear la cirugía

EANO guidelines for the diagnosis and treatment of meningiomas

Although meningiomas are the most common intracranial tumours, the level of evidence to provide recommendations for the diagnosis and treatment of meningiomas is low compared with other tumours such as high-grade gliomas. The meningioma task force of the European Association of Neuro-Oncology (EANO) assessed the scientific literature and composed a framework of the best possible evidence-based recommendations for health professionals. The provisional diagnosis of meningioma is mainly made by MRI. Definitive diagnosis, including histological classification, grading, and molecular profiling, requires a surgical procedure to obtain tumour tissue. Therefore, in many elderly patients, observation is the best therapeutic option. If therapy is deemed necessary, the standard treatment is gross total surgical resection including the involved dura. As an alternative, radiosurgery can be done for small tumours, or fractionated radiotherapy in large or previously treated tumours. Treatment concepts combining surgery and radiosurgery or fractionated radiotherapy, which enable treatment of the complete tumour volume with low morbidity, are being developed. Pharmacotherapy for meningiomas has remained largely experimental. However, antiangiogenic drugs, peptide receptor radionuclide therapy, and targeted agents are promising candidates for future pharmacological approaches to treat refractory meningiomas across all WHO grades

EANO guideline on the diagnosis and management of meningiomas

Meningiomas are the most common intracranial tumors. Yet, only few controlled clinical trials have been conducted to guide clinical decision making, resulting in variations of management approaches across countries and centers. However, recent advances in molecular genetics and clinical trial results help to refine the diagnostic and therapeutic approach to meningioma. Accordingly, the European Association of Neuro-Oncology (EANO) updated its recommendations for the diagnosis and treatment of meningiomas. A provisional diagnosis of meningioma is typically made by neuroimaging, mostly magnetic resonance imaging. Such provisional diagnoses may be made incidentally. Accordingly, a significant proportion of meningiomas, notably in patients that are asymptomatic or elderly or both, may be managed by a watch-and-scan strategy. A surgical intervention with tissue, commonly with the goal of gross total resection, is required for the definitive diagnosis according to the WHO classification. A role for molecular profiling including gene panel sequencing and genomic methylation profiling is emerging. A gross total surgical resection including the involved dura is often curative. Inoperable or recurrent tumors requiring treatment can be treated with radiosurgery, if the size or the vicinity of critical structures allows that, or with fractionated radiotherapy (RT). Treatment concepts combining surgery and radiosurgery or fractionated RT are increasingly used, although there remain controversies regard timing, type, and dosing of the various RT approaches. Radionuclide therapy targeting somatostatin receptors is an experimental approach, as are all approaches of systemic pharmacotherapy. The best albeit modest results with pharmacotherapy have been obtained with bevacizumab or multikinase inhibitors targeting vascular endothelial growth factor receptor, but no standard of care systemic treatment has been yet defined