Upfront stereotactic radiosurgery in patients with brain metastases from small cell lung cancer: retrospective analysis of 41 patients

BACKGROUND: Although the efficacy of prophylactic or therapeutic whole brain radiotherapy (WBRT) for brain metastases (BM) from small cell lung cancer (SCLC) is well established, the role of stereotactic radiosurgery (SRS) has yet to be determined. In the present retrospective analysis, we investigated whether upfront SRS might be an effective treatment option for patients with BM from SCLC. METHODS: We analyzed 41 consecutive patients with a limited number of BM (≤ 10) from SCLC who received SRS as the initial treatment. No prophylactic and therapeutic WBRT was given prior to SRS. The median patient age was 69 years and the median Karnofsky performance status (KPS) score was 90. Repeat SRS was given for new distant lesions detected on follow-up neuroradiological imaging, as necessary. Overall survival, neurological death, and local and distant BM recurrence rates were analyzed. The survival results were tested with three prognostic scoring systems validated for SCLC: Diagnosis-specific graded prognostic assessment (DS-GPA), Radiation therapy oncology group -recursive partitioning analysis and Rades’s survival score. RESULTS: One- and 2-year overall survival rates were 44% and 17%, respectively. The median survival time was 8.1 months. Survival results replicated the DS-GPA (P = 0.022) and Rades’s survival score (P = 0.034). On multivariate analysis, patients with high KPS (hazard ratio (HR): 0.308, P = 0.009) and post-SRS chemotherapy (HR: 0.324, P = 0.016) had better overall survival. In total, 95/121 tumors (79%) in 34 patients (83%) with sufficient radiological follow-up data were evaluated. Six- and 12-month rates of local control failure were 0% and 14%, respectively. Six- and 12-month distant BM rates were 22% and 44%, respectively. Repeat SRS, salvage WBRT and microsurgery were subsequently required in 18, 7 and one patient, respectively. Symptomatic radiation injury developed in two patients and both were treated conservatively. CONCLUSIONS: Our survival analyses with the validated prognostic grading systems suggested upfront SRS for limited BM from SCLC to be a potential treatment option, with patient survival being slightly more than eight months after SRS. Although SRS provided durable local tumor control, repeat treatment was needed in nearly half of patients to achieve control of distant BM

Accurate Detection of Tumor Infiltration by 11C-Methionine Positron Emission Tomography in a Patient with Central Nervous System Intravascular Lymphoma: A Case Report

Intravascular lymphoma (IVL) is a rare and clinically devastating subtype of extranodal diffuse large B-cell lymphoma with a distinct presentation. Diagnostic difficulty derives from marked variability in clinical presentations and nonspecific laboratory and radiological findings, especially when central nervous system (CNS) symptoms are the only manifestation. Establishing the diagnosis premortem thus remains a major challenge. We describe a 70-year-old male with CNS IVL. He presented with acute onset of neurocognitive impairments. Diffusion-weighted magnetic resonance imaging (MRI) showed multiple high-intensity areas suggesting occlusive cerebrovascular disease due to emboli, but extensive investigations detected no embolic sources. Intracranial neoplasm was included in a differential diagnosis based on elevated serum lactate dehydrogenase and interleukin 2 receptor levels. Gadolinium-enhanced MRI or 18-fluorodeoxyglucose positron emission tomography (PET) failed to demonstrate specific findings leading to a definite diagnosis, while 11C-methionine PET (MET-PET) distinctively demonstrated an area of focally increased MET uptake in the frontal cortex, suggesting the extent of tumor infiltration. Stereotactic biopsy was conducted under MET-PET imaging guidance and immunohistological examinations confirmed the proliferation and aggregation of CD20-positive lymphoma cells within the lumina of small blood vessels. The findings of the present case first suggest that MET-PET may provide important information on the diagnosis of CNS IVL and on the selection of the optimal site for brain biopsy. Further investigation is necessary to clarify whether positive findings on MET-PET are truly specific and pathognomonic for CNS IVL

Prospective study of 11C–methionine PET for distinguishing between recurrent brain metastases and radiation necrosis: limitations of diagnostic accuracy and long-term results of salvage treatment

Abstract Background On conventional diagnostic imaging, the features of radiation necrosis (RN) are similar to those of local recurrence (LR) of brain metastases (BM). 11C–methionine positron emission tomography (MET-PET) is reportedly useful for making a differential diagnosis between LR and RN. In this prospective study, we aimed to investigate the diagnostic performance of MET-PET and the long-term results of subsequent patient management. Methods The eligible subjects had enlarging contrast-enhanced lesions (>1 cm) on MR imaging after any form of radiotherapy for BM, suggesting LR or RN. However, it was difficult to differentiate LR from RN in these cases. From August 2013 to February 2017, MET-PET was performed for 37 lesions in 32 eligible patients. Tracer accumulation in the regions of interest was analysed as the standardised uptake value (SUV) and maximal lesion SUV/maximal normal tissue SUV ratios (LNR) were calculated. The cut-off value for LNR was provisionally set at 1.40. Salvage treatment strategies determined based on MET-PET diagnosis and treatment results were investigated. The diagnostic accuracy of MET-PET was evaluated by receiver operating characteristic (ROC) curve analysis. Results The median interval from primary radiotherapy to MET-PET was 19 months and radiotherapy had been performed twice or more for 13 lesions. The MET-PET diagnoses were LR in 19 and RN in 18 lesions. The mean values and standard deviation of LNRs for each diagnostic category were 1.70 ± 0.30 and 1.09 ± 0.25, respectively. At the median follow-up time of 18 months, final diagnoses were confirmed histologically for 17 lesions and clinically for 20 lesions. ROC curve analysis indicated the optimal LNR cut-off value to be 1.40 (area under the curve: 0.84), and the sensitivity and specificity were 0.82 and 0.75, respectively. The median survival times of patient groups with LR and RN based on MET-PET diagnosis were 14.8 months and 35.1 months, respectively (P = 0.035, log-rank test). Conclusions MET-PET showed apparently reliable diagnostic performance for distinguishing between LR and RN. The provisional LNR cut-off value of 1.4 in our institution was found to be appropriate. Limitations of diagnostic accuracy should be recognised in cases with LNR close to this cut-off value

The Very Long-Term Outcome of Radiosurgery for Classical Trigeminal ă Neuralgia

International audienceBackground: Radiosurgery is one of the neurosurgical alternatives for ă intractable trigeminal neuralgia (TN). Objective: Although acceptable ă short-/mid-term outcomes have been reported, long-term results have not ă been well documented. Methods: We report the long-term results in 130 ă patients who underwent radiosurgery for classical TN and were ă subsequently monitored through at least 7 years (median = 9.9, range = ă 7-14.5) of follow-up. Results: The median age was 66.5 years. A total of ă 122 patients (93.8%) became pain free (median delay = 15 days) after ă the radiosurgery procedure (Barrow Neurological Institute, BNI class I ă IIIa). The probability of remaining pain free without medication at 3, ă 5, 7 and 10 years was 77.9, 73.8, 68 and 51.5%, respectively. Fifty-six ă patients (45.9%) who were initially pain free experienced recurrent ă pain (median delay = 73.1 months). However, at 10 years, of the initial ă 130 patients, 67.7% were free of any recurrence requiring new surgery ă (BNI class I IIIa). The new hypesthesia rate was 20.8% (median delay of ă onset = 12 months), and only 1 patient (0.8%) reported very bothersome ă hypesthesia. Conclusions: The long-term results were comparable to those ă from our general series (recently published), and the high probability ă of long-lasting pain relief and rarity of consequential complications of ă radiosurgery may suggest it as a first and/or second-line treatment for ă classical, drug-resistant TN. (C) 2016 S. Karger AG, Base

The Very Long-Term Outcome of Radiosurgery for Classical Trigeminal Neuralgia.

BACKGROUND: Radiosurgery is one of the neurosurgical alternatives for intractable trigeminal neuralgia (TN). OBJECTIVE: Although acceptable short-/mid-term outcomes have been reported, long-term results have not been well documented. METHODS: We report the long-term results in 130 patients who underwent radiosurgery for classical TN and were subsequently monitored through at least 7 years (median = 9.9, range = 7-14.5) of follow-up. RESULTS: The median age was 66.5 years. A total of 122 patients (93.8%) became pain free (median delay = 15 days) after the radiosurgery procedure (Barrow Neurological Institute, BNI class I-IIIa). The probability of remaining pain free without medication at 3, 5, 7 and 10 years was 77.9, 73.8, 68 and 51.5%, respectively. Fifty-six patients (45.9%) who were initially pain free experienced recurrent pain (median delay = 73.1 months). However, at 10 years, of the initial 130 patients, 67.7% were free of any recurrence requiring new surgery (BNI class I-IIIa). The new hypesthesia rate was 20.8% (median delay of onset = 12 months), and only 1 patient (0.8%) reported very bothersome hypesthesia. CONCLUSIONS: The long-term results were comparable to those from our general series (recently published), and the high probability of long-lasting pain relief and rarity of consequential complications of radiosurgery may suggest it as a first- and/or second-line treatment for classical, drug-resistant TN

The Very Long-Term Outcome of Radiosurgery for Classical Trigeminal ă Neuralgia

International audienceBackground: Radiosurgery is one of the neurosurgical alternatives for ă intractable trigeminal neuralgia (TN). Objective: Although acceptable ă short-/mid-term outcomes have been reported, long-term results have not ă been well documented. Methods: We report the long-term results in 130 ă patients who underwent radiosurgery for classical TN and were ă subsequently monitored through at least 7 years (median = 9.9, range = ă 7-14.5) of follow-up. Results: The median age was 66.5 years. A total of ă 122 patients (93.8%) became pain free (median delay = 15 days) after ă the radiosurgery procedure (Barrow Neurological Institute, BNI class I ă IIIa). The probability of remaining pain free without medication at 3, ă 5, 7 and 10 years was 77.9, 73.8, 68 and 51.5%, respectively. Fifty-six ă patients (45.9%) who were initially pain free experienced recurrent ă pain (median delay = 73.1 months). However, at 10 years, of the initial ă 130 patients, 67.7% were free of any recurrence requiring new surgery ă (BNI class I IIIa). The new hypesthesia rate was 20.8% (median delay of ă onset = 12 months), and only 1 patient (0.8%) reported very bothersome ă hypesthesia. Conclusions: The long-term results were comparable to those ă from our general series (recently published), and the high probability ă of long-lasting pain relief and rarity of consequential complications of ă radiosurgery may suggest it as a first and/or second-line treatment for ă classical, drug-resistant TN. (C) 2016 S. Karger AG, Base