Advances of surgery and radiation therapy of glioblastoma and metastatic tumor

On the surgery for malignant gliomas, most cases are beyond the stage for desirable removal of tumors, because of the risk of damage to the normal function of surrounding brain tissue. The restriction of the surgical treatment has inevitably required postoperative radiation therapy. With a protocol aiming at removing tumors extensively and delivering high dose radiation to the tumor area, we treated 107 patients with cerebral glioblastoma. Wide removal of the tumor combined with intraoperative radiation therapy (IORT) was applied to expected resectable cases at the first surgery or at the second salvage surgery after conventional external radiation therapy. Thirty patients underwent extensive removal with IORT and demonstrated a 2-year survival rate of 60%. Fifty six patients were treated only by postoperative radiation therapy and a two-year survival rate was only 6.8%. The results apparently indicate that areas adjacent to the margin of almost complete removal should be irradiated with a sufficient dose to sterilize the remaining malignant remnants. As metastatic brain tumors without systemic metastasis seldom develop to multiple lesions, surgical removal followed by local radiation therapy would be ideal in order to prevent brain atrophy and dementia induced by whole brain irradiation. IORT would be also useful for its strong local effect to tumors and for shortening the hospital stay of patients.     

Treatment of locally advanced rectal cancer with external beam radiation, surgical resection, and intraoperative radiation therapy

To try to improve the local control and survival of patients with locally advanced rectal cancer we have used a combination of high-dose pre-operative radiation therapy to 5,040 cGy followed by surgical resection and intraoperative electron beam radiation therapy (IORT) when there was visible or palpable residual disease, microscopically positive surgical margins, or persisting tumor adherence. A total of 75 patients were taken to surgery for resection +/- IORT who did not have distant metastases. Of the 49 patients with primary tumors, 11 did not have IORT as the tumor was thought to be completely resected. Of these 11, there were two local recurrences and a 3-year survival of 71%. Thirty-six patients with primary tumors had resection (20 complete, 16 partial) plus IORT, with a 3-year survival of 58% and three local failures. Twenty-six additional patients were treated for locally advanced recurrence of whom four could not receive IORT because of pelvic size or the extent of tumor. Of the 22 who received IORT, 7/9 with complete resection, 2/8 with partial resection, and 1/5 with no resection had local control with an overall 3-year actuarial survival of 32%. The local control and survival results in the primary tumors appear favorable compared to other series in the literature and suggest benefit to the use of IORT. For patients treated for local recurrence, local control and long-term survival can be obtained, but the results are not as encouraging as for the primary tumors.     

Fibromatoses: from postsurgical surveillance to combined surgery and radiation therapy

The results of management of two groups of patients with musculoaponeurotic (desmoid tumors) and plantar fibromatoses seen at Massachusetts General Hospital (MGH) during the period 1970-1985 are examined: (a) 26 patients who had had surgical resection for their primary fibromatosis but whose surgical margins were positive and who received no further treatment; and (b) 24 patients who were treated for their primary or recurrent fibromatosis by radiation alone or combined with surgery. For the 26 patients who were only observed, despite the positive surgical margins, 9 have recurred; the actuarial continuous local control rate at 5 years was 68% (a median follow-up of 70 months). Five patients had gross disease left after surgery and all of them failed. Seventeen of 21 patients who had grossly complete resection have local control; the four failures have been salvaged. This result supports the rationale for a no treatment but a thorough and close follow-up policy for patients with positive margins after grossly complete resection of a primary desmoid or fascial fibromatosis. There is no risk of metastasis in these patients and hence the effort toward a conservative policy which defers radiation merits interest and further study. Of the second group, 23 patients were treated for gross disease and one patient for microscopic disease after surgical resection. All of the 10 patients who were treated for primary desmoid tumor have local control. Among the 14 recurrent desmoid tumors there have been five local failures, after treatment by radiation alone or radiation + surgery. Three patients treated by radiation alone are currently scored as incompletely regressed tumors. Accordingly 16 of the 24 patients are scored as local controls without evidence of disease and 19 of the 24 are scored as local control (complete response or partial but stable response).     

Controversy in the management of optic nerve glioma

The records of 16 patients with optic nerve glioma treated between 1961 and 1984 were reviewed. All patients except two had extension of tumor beyond the chiasm to the hypothalamus, adjacent brain and/or along the posterior optic tract. Eleven of 16 cases were biopsy-proven, two patients had craniotomy and visual inspection but no biopsy was performed, and in two cases the biopsy was not diagnostic. Fourteen patients received radiation therapy, usually consisting of 50 Gy in 5 weeks (range 40-56 Gy), one patient was treated surgically and one with chemotherapy. With a follow-up of 1 to 20 years, 7 of the 14 patients irradiated are alive, three patients are dead of disease at 3, 6 and 9 years post-treatment, three were lost to follow-up at 1, 8, and 8 years, and one is dead of intercurrent disease at 5.5 years. Overall vision was improved in five patients and stable in seven following treatment. In two patients, vision could not be evaluated because of young age at presentation. Four patients had recurrences. One was retreated with 30 Gy in 3 weeks and shows no evidence of disease at 20 years. The three other patients died of their disease. There is controversy over the best treatment for these patients. Based on these results and a review of the literature, the authors recommendation is to irradiate tumors with extension beyond the chiasm at the time of presentation rather than waiting for increasing symptoms because function that is lost may not always be recovered. Chemotherapy needs to be further investigated but holds promise, especially for the younger children.     

Preservation of visual fields after peri-sellar gamma-knife radiosurgery

Radiosurgical treatment of pituitary and peri-sellar tumors has become an increasingly utilized modality as an alternative to conventional radiotherapy and surgery. Such radiosurgery results in a relatively high dose of radiation to the optic chiasm. The clinical data establishing safe single-fraction doses to the chiasm is immature, although taken together previous literature suggests a recommended maximal dose of 8 Gy. Optic neuropathy, when it occurs, tends to take place within 2 years of treatment. We evaluated the visual fields of 20 sequential patients that received significant doses to the optic chiasm by Gamma-knife radiosurgery. There were 17 cases of pituitary adenoma and 3 cases of meningioma, and two patients refused follow-up testing. Preoperative visual field and cranial nerve examinations were done prior to radiosurgery and in follow-up, with a median follow-up of 24 months. There were no cases of quantitative visual field deficit induced by treatment. No patients developed symptomatic visual deterioration. Radiat. Oncol. Invest. 90:343-350, 2000. 2000 Wiley-Liss, Inc.     

Adjunctive radiation therapy for rectal carcinoma.

From 1977 through 1985, 113 patients received radiation therapy in conjunction with definitive surgery for adenocarcinoma of the rectum. Posttreatment consisted of a minimum follow-up of 4 years. Radiation was given as postoperative (eight patients), short-course preoperative (2,000 cGy/5 fx, 21 patients), or as full-course preoperative treatment (4,500-5,000 cGy, 84 patients). Three patients received chemotherapy as part of the adjuvant treatment. The local control for the total group was 90% (local failures, 11 of 113), and the rate of recurrence at any site (distant or local) was 30% (34 of 113). Local failure was not significantly influenced by pretreatment clinical findings, tumor grade, or surgical stage. Because of distant failures, overall recurrence was significantly associated with surgical stage--0% (0 of 15) for Astler-Coller A, 23% (7 of 30) for B1, 25% (7 of 28) for B2, and 50% (20 of 40) for B3 or C lesions (p less than 0.01). Locally advanced pretreatment clinical findings were not independent of surgical stage as predictors of outcome. In particular, 14 of the tumors that received full course preoperative radiation were initially either nearly obstructing, circumferential, or deeply fixed. However, by the time of surgery, they were A or B1 lesions (probably down-staged lesions). Only one of 14 (7%) ultimately failed with a local and distant recurrence. There were four cases (3.5%) of small bowel obstruction requiring surgical management. Overall, there were 12 complications (11%) requiring either surgical or major medical management. The complication rate was not associated with radiotherapeutic factors. A strong association was noted between complications and the surgeon. Of 66 patients who had surgery with two colorectal specialists, four (6%) had serious complications. Of the remaining 47 patients who had general surgeons, eight (17%) experienced serious complications.     

经翼点入路鞍区肿瘤的手术并发症及相应对策

目的:探讨经翼点入路显微切除鞍区肿瘤常见并发症相关因素及预防方法。方法:回顾性分析140例鞍区肿瘤的临床资料。结果:垂体瘤64例(62.5%),全切42例(65.6%),次全切22例(34.4%),视神经功能改善56例(87.5%),内分泌症状改善40例(62.5%),垂体柄保留62例(96.8%)。鞍上脑膜瘤48例,全切42例(87.5%),次全切除6例(12.5%),视神经功能改善40例(83.3%),内分泌症状改善38例(79.1%),垂体柄保留47例(97.9%)。颅咽管瘤28例,全切23例(83.3%),次全切除5例(16.7%),视神经功能改善20例(71.4%),内分泌症状改善21例(75%),垂体柄保留24例(85.7%);主要并发症包括视力恶化(8.4%),尿崩(17.2%),电解质紊乱(11.2%),偏瘫(2.5%)等。手术死亡3例(2.1%)。结论:术前详细检查明确肿瘤性质及周围组织关系,熟悉鞍区解剖及熟练掌握显微外科技术是减少手术并发症的关键,术中须仔细分离肿瘤与正常组织,首先定位并辨认保护好视神经、垂体柄、颈内动脉、下丘脑的穿支供血动脉及外展神经。     

Treatment of carcinoma of the skin with bone and/or cartilage involvement

From 1956 to 1978, 23 patients with stage T4 carcinoma of the skin of the head and neck were treated with radiotherapy (RT). There were nine patients with cancer of the skin of the nose, eight with tumors of the pinna, and six with lesions of the eyelids. Basal cell carcinoma (BCC) was seen in 61%, squamous cell carcinoma (SCC) in 26%, and 13% of patients had tumors with BCC and SCC features. The majority of patients had large tumors. Less than one-third of patients had smaller lesions, whereas three patients had intermediate-size tumors (greater than 2 cm to less than or equal to 5 cm). Of the 23 patients treated, nine had prior surgical therapy and recurrent or persistent tumor. The remaining 14 patients had no prior therapy. RT was given up to an average total dose of 55 Gy. The 5-year actuarial tumor control rate was 80%. Of the 23 patients treated, four had recurrent tumors. There were no recurrences among the 14 BCC patients, whereas there were four recurrences among the nine SCC and mixed histology patients. Of the four patients who had tumor recurrence, one was salvaged by subsequent radical surgery and three died of their tumor. No serious complications were observed in this group of 23 patients. There was no cartilage, bone, or soft-tissue necrosis noted. RT is a good treatment option and it may be treatment of choice in patients with BCC and SCC of the skin with cartilage or bone involvement. It provides an excellent chance of tumor control, good cosmesis, preservation of function, and a low incidence of complications.     

A study on the radiation tolerance of the optic nerves and chiasm after stereotactic radiosurgery

PURPOSE: To evaluate the risk of clinically significant radiation optic neuropathy (RON) for patients having stereotactic radiosurgery of benign tumors adjacent to the optic apparatus. METHODS AND MATERIALS: We reviewed the dose plans and clinical outcomes of 218 gamma knife procedures (215 patients) for tumors of the sellar and parasellar region (meningiomas, n = 122; pituitary adenomas, n = 89; craniopharyngiomas, n = 7 patients). Previous surgery or radiation therapy was performed in 156 (66%) and 24 (11%) patients, respectively. Median follow-up was 40 months (range 4-115). RESULTS: The median maximum radiation dose to the optic nerve was 10 Gy (range 0.4-16.0). Four patients (1.9%) developed RON at a median of 48 months after radiosurgery. All had prior surgery, and 3 of 4 had external beam radiotherapy (EBRT) in their management either before (n = 2) or adjuvantly (n = 1). The risk of developing a clinically significant RON was 1.1% for patients receiving 12 Gy or less. Patients receiving prior or concurrent EBRT had a greater risk of developing RON after radiosurgery (p = 0.004). CONCLUSION: RON occurred in less than 2% of our patients, despite the majority (73%) receiving more than 8 Gy to a short segment of the optic apparatus. Knowledge of the dose tolerance of these structures permits physicians to be more aggressive in treating patients with sellar or parasellar tumors, especially those with hormone-producing pituitary adenomas that appear to require higher doses to achieve biochemical remission.     

Effectiveness of novel combination chemotherapy, consisting of 5-fluorouracil, vincristine, cyclophosphamide and etoposide, in the treatment of low-grade gliomas in children

Low-grade gliomas (LGG), which account for about 30% of brain tumors in children, are usually treated with surgical excision and/or radiotherapy. For patients who have significant residual tumor after resection or relapse after radiation, the proper chemotherapy regimen has not yet been identified. Thirteen children diagnosed with LGG outside the cerebellum between January 1999 and December 2004, all of whom had significant residual tumor after surgical resection, relapsed after radiation or showed visual deterioration, were treated for 18 months with a multi-drug regimen of vincristine, etoposide, cyclophosphamide and 5-fluorouracil. Of the 7 patients who completed chemotherapy, 1 showed complete response (CR), 5 showed partial response (PR), and 1 had stable disease (SD). In 5 patients, chemotherapy was prematurely discontinued; 4 of these patients showed tumor progression and 1 had SD. One patient is still undergoing treatment. The side effects of chemotherapy were manageable. The median time to tumor response was 34 months (range, 2–82 months). The progression free survival was 67.3%. Pediatric LGG patients with residual tumor after surgery or who undergo relapse(s) may be successfully treated using our combination chemotherapy regimen.     

New development of surgical treatment for malignant brain tumors

The most important prognosticator for malignant brain tumor patients is the degree of tumor removal. On the other hand, surgical removal should not induce aggravation of the patient performance status. In accordance with the result, surgical planning for glioma should be carefully considered. However, there is no standard guide for preoperative planning to date. However, there is no standard guide for preoperative planning to the present. We attempted to divide gliomas into 5 stages according to the difficulty of the surgery and analyzed the relation between the removal rate and each stage. The results demonstrated that the stage is correlated with the removal rate. This staging might contribute to standardization of glioma surgery. For surgical planning of tumors around the motor area, fiber tractography and magnetoencephalography should be very useful. As an intraoperative examination, monitoring of motor evoked potential is necessary to resect tumors around the motor area. For resection of tumors around the speech area, functional brain mapping under awake surgery is the most reliable method. In addition to these techniques for safe surgery, neuro-navigation and chemical navigation using 5-aminolevulinic acid are used to achieve of the maximum removal rate. Finally, development of preoperative examinations, microsurgical technique, and intraoperative monitoring enabled us to do safer and move sure surgery.     

Evaluation of Computer-Assisted Quantitative Volumetric Analysis for Pre-Operative Resectability Assessment of Huge Hepatocellular Carcinoma

Purpose: Hepatic resection is arguably the preferred treatment for huge hepatocellular carcinoma (H-HCC).Estimating the remnant liver volume is therefore essential. This study aimed to evaluate the feasibility of usingcomputer-assisted volumetric analysis for this purpose. Methods: The study involved 40 patients with H-HCC.Laboratory examinations were conducted, and a contrast CT-scan revealed that 30 cases out of the participating40 had single-lesion tumors. The remaining 10 had less than three satellite tumors. With the consensus of theteam, two physicians conducted computer-assisted 3D segmentation of the liver, tumor, and vessels in each case.Volume was automatically computed from each segmented/labeled anatomical field. To estimate the resectionvolume, virtual lobectomy was applied to the main tumor. A margin greater than 1 cm was applied to thesatellite tumors. Resectability was predicted by computing a ratio of functional liver resection (R) as (Vresected–Vtumor)/(Vtotal–Vtumor) x 100%, applying a threshold of 50% and 60% for cirrhotic and non-cirrhotic cases,respectively. This estimation was then compared with surgical findings. Results: Out of the 22 patients who hadundergone hepatectomies, only one had an R that exceeded the threshold. Among the remaining 18 patients withnon-resectable H-HCC, 12 had Rs that exceeded the specified ratio and the remaining 6 had Rs that were < 50%.Four of the patients who had Rs less than 50% underwent incomplete surgery due to operative findings of moreextensive satellite tumors, vascular invasion, or metastasis. The other two cases did not undergo surgery becauseof the high risk involved in removing the tumor. Overall, the ratio of functional liver resection for estimatingresectability correlated well with the other surgical findings. Conclusion: Efficient pre-operative resectabilityassessment of H-HCC using computer-assisted volumetric analysis is feasible.     

Chiasmal gliomas: results of irradiation management in 57 patients and review of literature

Fifty-seven patients with optic gliomas, treated by megavoltage radiotherapy between May 1970 and March 1986, are retrospectively analyzed. The mean follow-up was 7.5 years (2.5-16.5). At presentation, 46% were under 10 years old, 40% had neurofibromatosis, and 51% had neurological and/or endocrinological signs. Twenty-one tumors (37%) were confined to the optic chiasm, and 36 tumors (63%) extended to the hypothalamus, the posterior optic tract, or the adjacent brain. Two among the 16 biopsy-proven tumors were high grade gliomas. Delivered tumor doses were 40 to 60 Gy in 5 to 7 weeks. Forty-nine patients were alive (five with tumor evolution) and eight had died (five from the tumor, one from cerebrovascular complication, two from intercurrent disease). Overall actuarial survival was 83.5% at 5 and 10 years. Control of the disease in 53 evaluables patients was: complete response in 8 (15%), partial response in 25 (46%), and no progression in 12 (22%). Progressive disease was observed in three patients and signs evocative of recurrence in five others. Stabilization of visual impairment or improvement of vision was recorded in 93% of patients who were evaluable. A critical review of the literature is presented and complications discussed. Radiotherapy seems thus effective in chiasmal gliomas and must be delivered in cases of rapidly developing symptoms visual, neurological, or endocrine.     

Wound complications following pre-operative radiotherapy for soft tissue sarcoma.

AIMS: We analysed wound complications in 43 patients with soft tissue sarcoma who were treated with combined pre-operative radiotherapy and surgery. METHODS: All patients received the same protocol of pre-operative radiotherapy at our institution. RESULTS: Thirty-six (84%) patients developed acute skin toxicity following radiotherapy. After wide local excision, 15 patients required primary soft tissue reconstruction with vascularized muscle transfer and four patients underwent free skin flap to enable wound closure as part of their primary surgery. Nineteen patients (44%) developed post-operative wound complications including 10 (23%) patients who required an additional surgical procedure. Four (27%) patients developed flap necrosis in a group of 15 who underwent primary vascularized soft tissue transfer. All required a second vascularized muscular flap. One elderly patient, who had grade 3 acute radiation skin toxicity, had an arterial graft and total hip arthroplasty for a femoral artery aneurysm and an avascular necrosis of the hip, respectively. In our series, age (> or = 40 years) was the only impact factor influencing wound complication after surgery following radiotherapy (P=0.06). CONCLUSIONS: Site of tumour, radiation field size, surgical resection volume, grade of acute radiation toxicity, co-morbidity, and smoking were not demonstrated to have predictive value in wound complication following pre-operative radiotherapy. Although previous papers suggested that vascularized soft tissue transfer could be useful reducing wound morbidity, our results could not confirm this.     

Results of Contemporary Surgical Management of Radiation Necrosis using Frameless Stereotaxis and Intraoperative Magnetic Resonance Imaging

OBJECTIVE: Radiation necrosis is a well-known complication of radiotherapy for malignant brain tumors. Although surgery was once considered the mainstay of treatment, no recent reports have evaluated the use of intraoperative magnetic resonance imaging (IOMRI) and frameless stereotaxis during surgical resection of radiation necrosis. In this retrospective review, we evaluate the effectiveness of surgical resection using frameless stereotaxis and IOMRI for the treatment of radiation necrosis. METHODS: From October 1999 through February 2002, 11 patients who had malignant brain tumors underwent surgery for radiation necrosis. The diagnosis of radiation necrosis was based primarily on MRI and clinical suspicion. Frameless stereotaxis was used in all patients and IOMRI was used in nine. All patients underwent at least one radiation treatment before surgery and nine patients had multiple treatments. Patient outcome was based on changes in steroid dose, Karnofsky Performance Score (KPS), and neurologic deficit. RESULTS: Optimal resection as confirmed by IOMRI was achieved in all patients by the use of frameless stereotaxis alone; no additional resection was performed in any patient. For nine patients taking steroids (mean preoperative dose 24 mg/day) before treatment of necrosis, all had a substantial reduction in steroid dosage (mean postoperative dose 8 mg/day) after surgical treatment. Postoperatively, KPS improved in four patients, remained stable in four, and worsened in three. Three complications that resulted from surgery included wound infection, asymptomatic carotid dissection, and pulmonary embolism; thus, overall morbidity including both surgical complications and neurologic deterioration was 54%. CONCLUSIONS: In this review, frameless stereotaxis was helpful in guiding the surgeon; however, IOMRI did not provide any additional benefit for the surgical treatment of radiation necrosis. Surgical treatment of radiation necrosis was associated with high risks of complication or neurologic deficit. Given the success of medical therapies, including hyperbaric oxygen, we believe that surgical treatment of radiation necrosis should be reserved for symptomatic patients in whom medical therapy has failed.     

The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas

Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity.     

Interstitial brachytherapy for metastatic brain tumors

Since December 1979, 14 patients with progressive metastatic brain lesions have been treated with temporary implantation of high-activity iodine 125 sources using stereotaxic techniques. Four patients had prior surgical resections, and 13 had been treated with external whole-brain radiotherapy. Nine patients had brachytherapy performed at recurrence 4 to 16 months after conventional radiation therapy; the other four had implants as an adjuvant "boost" to the tumor area from 2 to 4 weeks after external radiation. Six patients have since died: two with stable brain lesions at 4 and 22 weeks, respectively; three with progressive systemic and CNS tumors at 23, 24, and 29 weeks, respectively; and one with progressive CNS disease 116 weeks postimplant. The remaining eight patients are alive with a median follow-up of 63 weeks (range, 52-239+ weeks). Median survival for the entire group is 80 weeks. Brain tumor brachytherapy may be useful for palliation and possible long-term survival in selected patients with solitary metastatic disease.     

Stereotactic radiotherapy for malignancies involving the trigeminal and facial nerves

Involvement of a cranial nerve caries a poor prognosis for many malignancies. Recurrent or residual disease in the trigeminal or facial nerve after primary therapy poses a challenge due to the location of the nerve in the skull base, the proximity to the brain, brainstem, cavernous sinus, and optic apparatus and the resulting complex geometry. Surgical resection caries a high risk of morbidity and is often not an option for these patients. Stereotactic radiosurgery and radiotherapy are potential treatment options for patients with cancer involving the trigeminal or facial nerve. These techniques can deliver high doses of radiation to complex volumes while sparing adjacent critical structures. In the current study, seven cases of cancer involving the trigeminal or facial nerve are presented. These patients had unresectable recurrent or residual disease after definitive local therapy. Each patient was treated with stereotactic radiation therapy using a linear accelerator based system. A multidisciplinary approach including neuroradiology and surgical oncology was used to delineate target volumes. Treatment was well tolerated with no acute grade 3 or higher toxicity. One patient who was reirradiated experienced cerebral radionecrosis with mild symptoms. Four of the seven patients treated had no evidence of disease after a median follow up of 12 months (range 2-24 months). A dosimetric analysis was performed to compare intensity modulated fractionated stereotactic radiation therapy (IM-FSRT) to a 3D conformal technique. The dose to 90% (D90) of the brainstem was lower with the IM-FSRT plan by a mean of 13.5 Gy. The D95 to the ipsilateral optic nerve was also reduced with IM-FSRT by 12.2 Gy and the D95 for the optic chiasm was lower with FSRT by 16.3 Gy. Treatment of malignancies involving a cranial nerve requires a multidisciplinary approach. Use of an IM-FSRT technique with a micro-multileaf collimator resulted in a lower dose to the brainstem, optic nerves and chiasm for each case examined.     

A pre-operative chemoembolization therapy using lipiodol, cisplatin and gelatin sponge for hepatocellular carcinoma

The significance of pre-operative transcatheter arterial chemoembolization therapy using lipiodol, cisplatin and gelatin sponge (Gelfoam) for the prevention of the recurrence of hepatocellular carcinoma (HCC) was evaluated. On the 103 patients who underwent radical operations for HCC with a tumor size less than 10 cm, 52 patients received no pre-operative therapy (group C), and 51 patients received pre-operative chemoembolization using lipiodol, a chemotherapeutic agent and Gelfoam. Of these 51 patients, 37 patients received a combination of lipiodol, cisplatin and Gelfoam (group A), while the remaining 14 patients received lipiodol, adriamycin and Gelfoam (group B). The disease-free survival rates after surgery were compared between group A, group B and group C. The 2-year disease-free survival rates in group A, group B and group C were 72%, 46% and 54%, respectively. These rates therefore suggest that pre-operative chemoembolization using lipiodol, cisplatin and Gelfoam is a useful method to prevent the recurrence of HCC after surgery.     

Intensity-modulated radiotherapy for pituitary adenomas: the preliminary report of the Cleveland Clinic experience

PURPOSE: Intensity-modulated radiotherapy (IMRT) is being increasingly used for the treatment of pituitary adenomas. However, there have been few published data on the short- and long-term outcomes of this treatment. This is the initial report of the Cleveland Clinic's experience. METHODS AND MATERIALS: Between February 1998 and December 2003, 34 patients with pituitary adenomas were treated with IMRT. A retrospective chart review was conducted for data analysis. RESULTS: With a median follow-up of 42.5 months, the treatment has proven to be well tolerated, with performance status remaining stable in 90% of patients. Radiographic local control was 89%, and among patients with secretory tumors, 100% had a biochemical response. Only 1 patient required salvage surgery for progressive disease, giving a clinical progression free survival of 97%. The only patient who received more than 46 Gy experienced optic neuropathy 8 months after radiation. Smaller tumor volume significantly correlated with subjective improvements in nonvisual neurologic complaints (p = 0.03), and larger tumor volume significantly correlated with subjective worsening of visual symptoms (p = 0.05). New hormonal supplementation was required for 40% of patients. Younger patients were significantly more likely to require hormonal supplementation (p = 0.03). CONCLUSIONS: Intensity-modulated radiation therapy is a safe and effective treatment for pituitary adenomas over the short term. Longer follow-up is necessary to determine if IMRT confers any advantage with respect to either tumor control or toxicity over conventional radiation modalities.