Рецидивы метастазов в головном мозге после радиохирургического лечения. Существуют ли возможности стереотаксического лучевого лечения?

Цель исследования. Провести анализ результатов повторного радиохирургического (РХ) лечения пациентов с интракраниальными рецидивами метастазов в головной мозг (МГМ), после ранее проведенной РХ первично выявленных церебральных метастазов.Материалы и методы. Были изучены общая и безрецидивная выживаемость у 290 пациентов, получивших радиохирургическое лечение по поводу первично выявленных МГМ. Из них у 153 пациентов развились интракраниальные рецидивы, а 73 -проведено повторное радиохирургическое лечение по поводу новых (дистантных) метастазов.Результаты. Медиана общей выживаемости (ОВ) пациентов с дистантными метастазами (ДМ) составила 9,0 месяцев, а в группе без ДМ – 10,2 мес. (p = 0,3556). Статистически значимыми факторами прогноза развития ДМ (на момент проведения первой радиохирургии) являются: множественное (>3) метастатическое поражение головного мозга, плохой функциональный статус (индекс Карновского ≤70) и наличие меланомы как первоисточника метастазирования. Наличие ДМ, в целом по группе, не ухудшает общую выживаемость, а ОВ в группе пациентов с повторной РХ существенно выше (22,4 месяца,95% ДИ 14,8–38,6). Поэтому прогноз пациента с ДМ не является однозначно плохим, как это предполагалось ранее.Выводы. Повторная РХ дистантных метастазов увеличивает время жизни по сравнению с группой пациентов без локального лечения ДМ. Следовательно, повторная радиохирургия интракраниальных рецидивов приводит к улучшению выживаемости у части пациентов. Классификация интракраниальных рецидивов на основе ожидаемых результатов лечения в различных клинических ситуациях позволяет оптимизировать тактику лечения пациентов этой группы

Использование современных методов МРТ-визуализации для планирования стереотаксических биопсий опухолевых новообразований головного мозга

Aim of the study. To evaluate the influence of modern MRI imaging, CT- and MRI fusion in STB planning on effectiveness of morphological verification and risks of intraoperative complications.Materials and methods. The most common indications for brain tumor biopsy is definitive diagnosis of the intracranial lesion and differentiation of the neoplastic and non-neoplastic pathology. During 2019 170 patients (95 men and 75 femmes) 7–69 years old underwent stereotactic biopsy an Integra LifeSciences Corporation Cosman–Roberts–Wells® (CRW®) system. In 80 cases, we used CT and MRI fusion by NeuroSight program to select the target point, entry point and trajectory of the brain biopsy. In 90 cases we use only CT images for stereotactic brain biopsy planning.Results. Among 80 patients with use of combined CT-MRI fusion only one case was not histologically verified. In 90 patients with use of only CT-imaging for STB 3 cases were histologically not verified. There were no hemorrhagic complications among 80 patients in CT-MRI fusion group. In 3 cases intracranial hematomas were identified that required surgical treatment after STB with use of CT-imaging for STB panning.Conclusion. The use of modern MRI and PET-CT imaging for STB planning increases its informativity and reduces the probability of hemorrhagic complications. Stereotactic biopsies remain a safe and reliable method for obtaining histological material. The use of modern imaging methods in biopsy planning increases their accuracy and reduces possible complications.Цель исследования: оценить влияние совмещения МР- и интраоперационных КТ-последовательностей, выполненных при планировании стереотаксической биопсии, на результативность гистологического диагноза и безопасность стереотаксической биопсии.Материал и методы. В работу включены данные 170 пациентов (95 мужчин и 75 женщин), которым по различным причинам в 2019 г. выполнена стереотаксическая биопсия на аппарате Cosman–Roberts– Wells® (CRW®) фирмы Integra LifeSciences Corporation. Возраст пациентов 7–69 лет. В 80 наблюдениях для совмещения изображений интраоперационной КТ головного мозга с данными предоперационной МРТ в различных режимах, для выбора точки мишени, траектории забора материала и места входного отверстия использовали программу NeuroSight Arc®.Результаты. Из 80 пациентов, у которых мы использовали совмещение КТ и МРТ, только у 1 пациента не удалось получить гистологический диагноз. В группе из 90 пациентов, которым для расчетов проводилась только интраоперационная КТ, в 3 случаях не удалось получить гистологический диагноз. В группе из 80 пациентов не отмечалось геморрагических осложнений. В группе из 90 пациентов, которым выполнялась только интраоперационная КТ, в 3 случаях были выявлены внутричерепные гематомы, потребовавшие хирургического вмешательства.Заключение. Использование современных методов нейровизуализации, таких как МРТ и ПЭТ-КТ, в планировании и проведении стереотаксической биопсии повышает ее информативность и снижает риск развития постоперационных осложнений

RESULTS OF RADIOSURGICAL AND DRUG TREATMENT OF PATIENTS WITH BRAIN METASTASES

The study objective is to study overall survival and the rate of intracranial recurrences in patients with brain metastases after radiosurgery as single treatment.Materials and methods. The results of radiosurgical treatment of 579 patients with brain metastases (248 men and 331 women) were analyzed. The sources of brain metastases were breast cancer (164 patients), non-small-cell lung carcinoma (162), melanoma (123), kidney cancer (87), colorectal cancer (43). Median cumulative tumor volume, maximal lesion volume, number of brain metastases in the studied patient group were 5.4 cm3, 3.6 cm3, and 4, respectively. Mean marginal dose of ionizing radiation was 22 Gy (15–24 Gy). Mean follow-up duration was 13.4 months.Results. Overall survival of patients at 12 and 24 months was 42.8 and 24.8 %, respectively, with median overall survival after radiosurgery of 9.8 months (95 % confidence interval: 8.5–11.3). Local control of metastatic lesions was achieved in 81.3 % patients. Survival without local recurrence at 12 months was 66.7 %. Distant metastases developed in 235 (52.4 %) of 449 patients for whom radiological data was available. Survival without distant metastases at 12 and 24 months was 41.5 and 20.9 %, respectively. Multifactor analysis has shown that prognostic factors for long-term survival in patients with brain metastases were presence of breast cancer metastases in the brain, limited (4 lesions or less) number of brain metastases, high functional status, and absence of extracranial metastases. Increased survival duration was also associated with targeted therapy (p = 0.0412) and repeated radiosurgery to treat intracranial recurrences (р <0.0001).Conclusion. Radiosurgical treatment of patients with brain metastases confers higher median overall survival (up to 9.8 months) than the same criterion (7.1 months) in the 1st class patients (per the recursive partitioning analysis scale) who received irradiation of the whole brain as single treatment. Repeated radiosurgery in cases of intracranial recurrences and targeted therapy confer increased overall survival of patients with brain metastases

Primary cerebral lymphoma. Mental disorders after biopsy (case report)

The article reviews the literature on the diagnosis and treatment of primary lymphomas of the central nervous system and describes a case of mental disorder before and after surgery in a patient with lymphoma of the third ventricle. Using an interdisciplinary approach, psychopathological dynamics is analyzed taking into account the structural and functional state of the brain, which allowed to clarify the possible causes of mental disorders and methods of treatment. Acute onset of confusion and headache was associated with disorders of the liquor outflow, due to the localization of the tumor. The reason for the disintegration of consciousness after surgery was brain hypoxia and the instability of connections between cerebral structures associated with it. The peculiarity of the consciousness recovery could be determined by premorbid personal traits

STEREOTACTIC RADIOTHERAPY AND RADIOSURGERY IN THE TREATMENT OF PATIENTS WITH BRAIN PILOID ASTROCYTOMAS OF DEEP LOCATION

Piloid astrocytoma (PA) is a low-grade (WHO grade I) glial tumor that is more common in pediatric patients. According to the data of many authors, stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) promote long-term remission or delayed tumor progression in patients with inoperable tumors after incomplete removal of a tumor and with its recurrence. So it is urgent to determine the place and role of SRS and SRT in the combination treatment of patients with deeply located PA.Subjects and methods. In the period April 2005 to May 2010, the Department of Radiology and Radiosurgery, Neurosurgery Research Institute, Russian Academy of Medical Sciences, treated 101 patients diagnosed as having intracranial PA. Of them there were 70 children (aged 17 years inclusive) and 31 adults; 51 men and 50 women. The median age was 15.1 years (9.8 years for children and 28.7 years for adults). Tumor was histologically pre-verified in 90 (89.2 %) patients (tumor ablation in 83 cases and biopsy in 7). The diagnosis of PA was made on the basis of clinical and X-ray data in 11 (10.8 %) patients. ART was used in most cases (n = 66 (66.3 %)). SRS was performed in 35 (34.7 %) patients.Results. The median follow-up of the patients from the onset of disease was 52 months (range 2–228 months). Eighty-eight (87 %) patients could be followed up. On completion of the follow-up (December 2010), 87 (98.8%) of the 88 patients receiving SRT and SRS were alive. The median follow-up from the initiation of radiotherapy was 22.7 months (range 6–60 months). Tumors were enlarged in 20 (22.7 %) patients; those were due to cysts in 18. Eighteen patients were reoperated on. Histological specimens were examined and comparatively analyzed in 12 operated patients. The tumor changes accompanied by a reduction of the solid component and an increase of the cystic component were found to be a manifestation of tumor reactive-degenerative alterations as a consequence of radiation pathomorphi sm.Conclusion. SRT and SRS are effective treatments in patients with primary or recurrent PA irrespective of the tumor site and must be performed early after non-radical tumor removal. At present (median follow-up 22.7 months), tumor growth is controlled in 98 % of th