Gamma Knife radiosurgery in the management of brainstem metastases

Background

Metastases to the brainstem portend a poor prognosis and present a challenge in clinical management. Surgical resection is rarely a viable option.

Methods

Post-treatment MRI scans of patients with brainstem metastases treated with radiosurgery were used to determine local control and disease progression. Median survival was calculated using Kaplan–Meier analysis. Univariate and multivariate analyses were performed using log-rank test and Cox proportional hazards model, respectively.

Results

Thirty-two consecutive patients with brainstem metastasis underwent Gamma Knife radiosurgery. Median age was 50 years. Median tumor volume was 0.71 cm³ and median tumor margin dose was 13 Gy. Seventeen of 32 patients received WBRT prior to stereotactic radiosurgery. Median survival was 5.2 months. There was a statistically significant difference in survival based on RTOG recursive partition analysis (RPA) class. Median survival of patients categorized as RPA class I was 19.2 months, RPA class II was 8.4 months, and RPA class III was 1.9 months. The overall local tumor control rate was 87.5%. There were no acute complications following stereotactic radiosurgery and no evidence of radiation necrosis noted on post-treatment MRI scans.

Conclusion

Stereotactic radiosurgery is an effective treatment for brainstem metastases and should be considered especially for patients with good performance status.     

Fatal glioblastoma after Gamma Knife radiosurgery for arteriovenous malformation in a child

We describe a fatal case of glioblastoma multiforme that was induced by Gamma Knife radiosurgery (GKS; Elekta AB, Stockholm, Sweden) for an arteriovenous malformation (AVM). A 4-year-old girl presented with repeated convulsions. Imaging studies revealed an AVM located in the right thalamus. One year after initial symptoms, GKS was performed to obliterate the nidus. The maximum and marginal radiation doses were 32 and 16 Gy, respectively. Seventy months after GKS, the patient represented with severe headache. MRI showed a poorly demarcated tumor with heterogeneous gadolinium enhancement in the right thalamus and adjacent to the white matter of the temporal lobe. After a generalised convulsion, the patient deteriorated into a deep coma. CT scans showed severe brain swelling with intratumoral hemorrhage. An emergency craniotomy was performed, and the hematoma was removed. During this surgery, a tumor mass, which was found adjacent to the hematoma, was resected. Microscopic examination revealed glioblastoma multiforme. Despite intensive treatment, the patient died 1 month after surgery. A GKS-induced secondary tumor is a rare but serious complication. It is important to be aware of the adverse effects of GKS, including secondary neoplasms, before its clinical application, especially in young patients.     

RapidArc与Novalis Knife在多发脑转移瘤SRS中的剂量学比较

目的:比较基于多叶准直器的RapidArc与基于圆形限光筒的Novalis Knife在多发脑转移瘤立体定向放射外科（SRS）中的剂量学差异。方法:选取10例已进行Novalis Knife治疗的多发脑转移瘤患者（转移瘤3~5个/人）,共37个转移瘤。重新设计单中心、非共面4弧的RapidArc SRS计划,靶区处方剂量统一为16 Gy。比较Novalis Knife计划和RapidArc SRS计划中靶区的剂量适形度指数和均匀性指数、靶区周围剂量梯度指数、正常脑组织等剂量线体积（V16、V12、V9、V6、V3）以及治疗所需的机器跳数。结果:RapidArc SRS计划相较于Novalis Knife计划,适形度指数更接近于1（0.79[±]0.10 vs 0.50[±]0.22, P=0.000）,均匀性指数更接近于0（0.07[±]0.01 vs 0.15[±]0.07, P=0.000）,但靶区周围剂量梯度指数较大（15.92[±]12.43 vs 5.05[±]3.53, P=0.000）。对于正常脑组织等剂量线体积,RapidArc SRS计划中V16明显小于Novalis Knife计划（P=0.005）;两计划的V12、V9无明显差异（P=0.445, 0.059）;而RapidArc SRS计划中V6、V3明显大于Novalis Knife计划（P=0.005, 0.005）。RapidArc SRS计划的机器跳数明显少于Novalis Knife计划（P=0.005）。结论:RapidArc SRS计划通过设置单一治疗等中心可实现颅内多个转移瘤的同步放射外科治疗,具有更高的靶区剂量适形度及均匀性;但靶区周边剂量跌落陡度不及Novalis Knife计划,正常脑组织低剂量受照范围较大。治疗依从性较差的多发脑转移患者可考虑选择治疗效率更高的RapidArc技术,并根据临床实际情况调整剂量分割模式,以减少放射损伤风险。     

Effect of transection in the brainstem on short-term maintenance of deoxycorticosterone-salt hypertension

Sections were made to determine supraspinal areas that participate in the maintenance of deoxycorticosterone (DOC)-salt hypertension. Blood pressure (BP) falls after cuts which severed: (a) the lateral connections between pons and midbrain, (b) the pathways between caudal hypothalamus and midbrain, and (c) parasagittal between medial and lateral hypothalamus. No changes in BP were found either after coronal cuts that severed a central area located at: (a) the pons-midbrain edge, (b) above the caudal hypothalamus, and (c) the level of the anterior hypothalamic area, or after parasagittal cuts at the level of the capsula interna or after a hypophysial stalk lesion. These results implicate the hypothalamus in the maintenance of DOC-salt hypertension. The hypothalamus-neural lobe system appears not to be involved in the lowering of BP found.     

刃针治疗神经根型颈椎病疗效观察

目的观察刃针治疗神经根型颈椎病的疗效。方法将150例患者随机分为治疗组和对照组,治疗组采用刃针微创治疗术,对照组则采用电针常规取穴治疗,两组进行疗效比较。结果与结论治疗组优良率和总有效率分别为75．3％和95．3％,对照组分别为52．3％和87．7％,两组总有效率差异虽无统计学意义（P〉0．05）,但治疗组优良率明显优于对照组,差异有统计学意义（P〈0．01）。     

穴位埋线结合针刀治疗顽固性网球肘疗效观察

目的观察针刀结合穴位埋线与单纯针刀、穴位埋线治疗顽固性网球肘的临床疗效差异。方法将120例顽固性网球肘患者随机分为针刀结合穴位埋线组（针线组）和针刀组及埋线组各40例,采用单盲法,针线组采取针刀结合穴位埋线治疗,针刀组采取针刀治疗,埋线组采取穴位埋线治疗。1个疗程后观察三组患者的临床疗效,并进行对比分析。结果针线组与针刀组、埋线组有效率分别为90．0％与82．5％、85．0％,三组有效率差异无统计学意义（P〉0．05）,针线组治愈率与其他两组相比较差异具有统计学意义（P〈0．01）。结论针刀结合穴位埋线治疗顽固性网球肘具有治愈率高的特点。     

Overeating and obesity produced by interruption of the caudal connections of the hypothalamus: evidence of hormonal and metabolic disruption.

Surgical transection of the posterior connections of the medial basal hypothalamus is much more effective in producing hyperphagia and obesity in female than in male rats. The hyperphagia of female rats can be attenuated by daily injections of estradiol. When starved to the weight of control animals, previously obese female rats with cuts through the posterior hypothalamus showed only mild hyperphagia but quickly returned to their elevated body weights. The results indicated that hormonal and metabolic disturbance are important factors in determining food intake and body weight following damage to the ventromedial hypothalamus.     

Gamma Knife radiosurgery for numerous brain metastases: is this a safe treatment?

Gamma Knife (GK) radiosurgery has recently been employed in patients with numerous brain metastases (METs), even those with 10 or more lesions. However, cumulative irradiation doses to the whole brain (WB), with such treatment, have not been determined.

Since the GammaPlan ver. 5.10 (ver. 5.31 is presently available, Leksell GammaPlan) became available in November 1998, 92 GK procedures have been performed for 80 patients with 10 or more brain METs at our facility. The median lesion number was 17 (range: 10–43) and the median cumulative volume of all tumors was 8.02 cc (range: 0.46–81.41 cc). The median selected dose at the lesion periphery was 20 Gy (range: 12–25 Gy). Based on these treatment protocols, the cumulative irradiation dose was computed.

The median cumulative irradiation dose to the WB was 4.71 (range: 2.16–8.51) Gy. The median brain volumes receiving >2 Gy, >5 Gy, >10 Gy, >15 Gy, and >20 Gy were 1105 (range 410–1501) cc, 309 (46–1247) cc, 64 (13–282) cc, 24 (2–77) cc, and 8 (0–40) cc, respectively.

The cumulative WB irradiation doses for patients with numerous radiosurgical targets were not considered to exceed the threshold level of normal brain necrosis.     

Backstabbing—a report of an unusual case

A case of a 25-year-old male with a deep knife stab injury in the back is reported. The stab wound penetrated the left thorax and the left lung was injured, a thoracotomy was performed and the patient survived. The injured man could not remember what had happened, his bag was missing and the incident was therefore considered to be due to a robbery. Further results of the police investigations and the forensic pathology inspection revealed an extremely unusual accident constellation.