Samir V. Sejpal

Atypical meningioma: Randomized trials are required to resolve contradictory retrospective results regarding the role of adjuvant radiotherapy

BACKGROUND The role of postoperative radiation (RT) in atypical meningioma remains controversial. MATERIALS AND METHODS We report a retrospective review of outcomes and prognostic factor analysis in 158 patients treated between 2000 and 2010, and extensively review the literature. RESULTS Following resection, 23 patients received immediate RT, whereas 135 did not. Median progression-free survival (PFS) with and without RT was 59 (range 43-86) and 88 (range 64-123) months. For Simpson grade (G) 1-3 resection, with and without RT, median PFS was 48 (2-80) versus 96 (88-123) months and for Simpson G4, it was 59 (6-86) versus 47 (15-104) months (P = 0.4). The rate of 5-year overall survival (OS) with and without RT was 89% and 83%, respectively. On univariate analysis, Simpson G4 (HR 3.2, P = 0.0006) and brain invasion (HR 2.2, P = 0.03) were significantly associated with progression, whereas age >60 years (HR 9.7, P = 0.002), mitoses >5 per 10 high-power field (0.2, P = 0.0056), and Simpson G4 (HR 2.4, P = 0.07) were associated with higher risk of death. We summarized 22 additional reports, which provide very divergent results regarding the benefit of RT. CONCLUSIONS In our series, adjuvant RT is surprisingly associated with worse PFS and OS, and this is more likely to be due to selection bias of referring tumors with more aggressive characteristics such as elevated Ki-67 and brain invasion for adjuvant RT, rather than a direct causal effect of adjuvant RT. Although there is a trend toward improved PFS with adjuvant RT after subtotal resection, no improvement was noted in OS. Multivariate analysis did not yield statistical significance for any of the factors including Simpson grades of resection, adjuvant RT, or six pathological defining features. The relatively divergent results in the literature are most likely explained by patient selection variability; therefore, randomized trials to adequately address this question are clearly necessary.

Intra-operative pubic arch interference during prostate seed brachytherapy in patients with CT-based pubic arch interference of ≤1 cm

PURPOSE There are only a few reports on the frequency of intra-operative pubic arch interference (I-PAI) during prostate seed brachytherapy (PB). MATERIALS AND METHODS Two hundred and forty-three patients with a CT-based pubic arch interference (PAI) of < or =1 cm and a prostate volume of < or =50-60 cc underwent PB. Those patients requiring needle repositioning by > or =0.5 cm on the template were scored as having I-PAI. The incidence of I-PAI and its impact on biochemical control were analyzed. RESULTS Intra-operative PAI was encountered in 47 (19.3%) patients. Forty two patients (17.3%) had I-PAI in 1-2 needles, two (0.8%) had I-PAI in four needles and three patients (1.2%) had I-PAI in six needles. Overall, 1.4% of needles required repositioning due to I-PAI. BMI>27 kg/m(2) and wider (>75 mm) pubic bone separation at mid ramus (PS-ML) were associated with a lower incidence of I-PAI. At a median follow-up of 50.1 months, the 3- and 5-year bPFS was 97.3% and 95.2%, respectively. The 5-year bPFS rates for patients with and without I-PAI were 95.6% and 95%, respectively (p=0.28). CONCLUSIONS The use of CT-based PAI of < or =1cm as a selection criterion for PB is a simple and reliable method for minimizing the incidence of I-PAI and maintaining excellent biochemical control rates.

Palliative Radiation Therapy in the Management of Brain Metastases, Spinal Cord Compression, and Bone Metastases

Radiation therapy plays an important role in both curative and palliative cancer treatment. Palliative radiation therapy is given to alleviate symptoms, restore function, relieve suffering caused by cancer, and improve quality of life. Pain relief, control of bleeding or ulceration, prevention of impending compression or obstruction from tumor, and shrinkage of tumor masses causing symptoms are indications for palliative radiotherapy. Palliative radiotherapy is a very effective tool in alleviating pain symptoms and generally well tolerated. Common fractionation schemes are 8 Gy delivered in one fraction and 30 Gy delivered in 10 fractions. This article discusses general principles of administering palliative radiation therapy. Site-specific treatment is addressed, divided into palliative radiotherapy for brain metastases, spinal cord compression, and bone metastases. In each of these areas, we discuss presentation, management, and therapeutic strategies.

Low-Dose Gamma Knife Radiosurgery for Vestibular Schwannomas: Tumor Control and Cranial Nerve Function Preservation After 11 Gy

Objectives This study aims to report tumor control rates and cranial nerve function after low dose (11.0 Gy) Gamma knife radiosurgery (GKRS) in patients with vestibular schwannomas. Methods A retrospective chart review was performed on 30 consecutive patients with vestibular schwannomas treated from March 2004 to August 2010 with GKRS at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. The marginal dose for all patients was 11.0 Gy prescribed to the 50% isodose line. Median follow‐up time was 42 months. The median treatment volume was 0.53 cm3. Hearing data were obtained from audiometry reports before and after radiosurgery. Results The actuarial progression free survival (PFS) based on freedom from surgery was 100% at 5 years. PFS based on freedom from persistent growth was 91% at 5 years. One patient experienced tumor progression requiring resection at 87 months. Serviceable hearing, defined as Gardner‐Robertson score of I‐II, was preserved in 50% of patients. On univariate and multivariate analyses, only higher mean and maximum dose to the cochlea significantly decreased the proportion of patients with serviceable hearing. Conclusion Vestibular schwannomas can be treated with low doses (11.0 Gy) of GKRS with good tumor control and cranial nerve preservation.

Radiation-Resistant Prostate Cancer and Salvage Prostatectomy

One in six men in the Unites States will be diagnosed with prostate cancer accounting for an incidence of 233,000 cases per year. Nearly half of the men that choose treatment will receive radiation therapy (RT), and depending on the aggressiveness of their tumor, an unknown but significant percentage will have radiation refractory cancers. Identifying recurrences post RT remains challenging with limited biomarkers that can identify persistent cancer. In this chapter, we will highlight methods to detect recurrence after RT, and discuss the oncologic and function outcomes of surgical salvage treatment.

Using intensity-modulated radiotherapy to spare the kidney in a patient with seminoma and a solitary kidney: a case report.

AIMS AND BACKGROUND Radiotherapy-related kidney injury is multifactorial and influenced by radiation dose-volume distributions, patient-related factors, and chemotherapy. Traditional radiation parameters for the kidney are based on pre-intensity-modulated radiotherapy (IMRT) data and focus on limiting the volume receiving high dose. We report a case of testicular seminoma with paraaortic adenopathy in a patient with a solitary kidney treated with radiotherapy. METHODS A comparison was performed for IMRT and two 3D-conformal techniques. In our case, IMRT reduced the volume of kidney receiving high dose but increased the volume receiving low dose. RESULTS Given the lack of data for suggesting that large renal volumes treated to low doses would cause excess toxicity, the consensus opinion was to proceed with IMRT. The patient tolerated treatment well without evidence of radiotherapy-related kidney injury. CONCLUSIONS As patients are treated with increasingly complex techniques such as IMRT, understanding low dose effects and monitoring low dose parameters may become clinically important.