RESUMEN
Effectiveness of Gamma Knife radiosurgery (GKRS: Elekta AB, Stockholm, Sweden) for patients with metastatic brain disease and the prognostic factors influencing their survival were analyzed in a 5 year retrospective data analysis (July 2001 to June 2006). Kaplan-Meier survival curves were constructed using univariate and multivariate analyses with the respective salient prognostic factors. This study analyzed data on 330 patients with brain metastases who underwent GKRS. Lung carcinoma (55%) was the most common primary cancer followed by breast (17.8%), melanoma (9.4%), colorectal (4.8%) and renal (3.9%). The median survival for all patients was 8 months. Survival ranged from 13 months for breast metastases, 10 months for renal, and 8 months for lung to 5 months for colorectal and melanoma. Mean age of patients was 58.5 years (range 18-81). Melanoma patients were younger with a mean age of 49 and also had the highest number of lesions (3.8) when compared to patients with renal (2.5), lung (2.8), colorectal (3) and breast (3.6). When stratified according to the number of lesions patient survival was 8 months (one to three lesions), 7.5 months (four or five lesions) and 7 months (six lesions or more). Mean Karnofsky Performance Status score (KPS) was 77 and survival dropped significantly from 8 months to 4.5 months if KPS was less than 70. Survival improved with a KPS of 70 or more, regardless of the number of lesions treated. Selection of patients based on the number of lesions may not be justified. A prospective trial is required to further define the prognostic factors affecting survival.
Asunto(s)
Neoplasias Encefálicas/secundario , Carcinoma/secundario , Melanoma/secundario , Selección de Paciente , Radiocirugia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Encefálicas/mortalidad , Neoplasias Encefálicas/cirugía , Neoplasias de la Mama/patología , Carcinoma/mortalidad , Carcinoma/cirugía , Neoplasias Colorrectales/patología , Femenino , Humanos , Estimación de Kaplan-Meier , Estado de Ejecución de Karnofsky , Neoplasias Pulmonares/patología , Masculino , Melanoma/mortalidad , Melanoma/cirugía , Persona de Mediana Edad , Cuidados Paliativos , Estudios Retrospectivos , Neoplasias Cutáneas/patología , Resultado del Tratamiento , Adulto JovenRESUMEN
A 47-year-old woman and a 45-year-old man with gradually progressive fourth cranial nerve palsy underwent stereotactic radiosurgery for presumed fourth cranial nerve schwannomas with the gamma knife at a marginal tumor dose of 14 and 13 Gy, respectively. In one patient, the ocular misalignment disappeared; in the other patient, it stabilized. MRI showed shrinkage of the tumors. These patients represent the second and third reported cases of presumed fourth cranial nerve schwannoma treated with radiosurgery and the first cases with substantial follow-up information.
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Neoplasias de los Nervios Craneales/cirugía , Neurilemoma/cirugía , Radiocirugia , Enfermedades del Nervio Troclear/cirugía , Neoplasias de los Nervios Craneales/diagnóstico , Diplopía/diagnóstico , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neurilemoma/diagnóstico , Enfermedades del Nervio Troclear/diagnósticoRESUMEN
Although two-thirds of invasive breast cancers and half of non-invasive breast cancers are amenable to lumpectomy, only about 70% of such patients choose breast conservation. Of that group, up to one-third do not follow-up with radiation therapy despite it being clinically indicated. The reasons include the patient's and surgeon's attitude toward breast conservation as well as the inconvenience and distance of a suitable radiation facility. The advent of shorter courses of radiation therapy may encourage more patients to seek adjuvant therapy. An increasingly popular and more convenient alternative to traditional whole-breast radiation therapy in patients with early-stage breast cancer is accelerated partial breast irradiation (APBI), for which the American Society of Breast Surgeons and the American Brachytherapy Society have promulgated guidelines for candidate selection. Although several methods are emerging, the most widely used brachytherapy technique utilizes the MammoSite single-catheter balloon brachytherapy device. In a best practices symposium convened in 2006, breast surgeons from academic and community practices with extensive experience in balloon brachytherapy developed general guidelines for integrating APBI into a breast surgical practice. Important considerations include patient age, histology, tumor location and size, and breast size. Thoughtful lumpectomy planning is essential to optimize balloon placement. Real-time sonographic guidance is essential as the surgeon should attend closely to volume excised and cavity shape. A cavity evaluation device can act as a place holder while patient suitability for APBI is considered. Many breast surgeons expert in this procedure insert the balloon catheter in the office either through a de novo skin entrance site removed from the lumpectomy incision or through the original incision. Optimally, insertion occurs within 2-3 weeks after lumpectomy. Close and continual communication with the radiation oncologist is essential to assure optimal outcomes. In this review, several key aspects of a successful APBI program from a surgeon's perspective as well as a consensus panel from a best practices symposium on the topic herein are highlighted.
Asunto(s)
Braquiterapia/métodos , Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Mastectomía Segmentaria , Rol del Médico , Adulto , Anciano , Terapia Combinada , Femenino , Humanos , Persona de Mediana EdadRESUMEN
OBJECT: The brain shows remarkable capacity for plasticity in response to injury. To maximize the benefits of current neurological treatment and to minimize the impact of injury, the authors examined the ability of commonly administered drugs, dextroamphetamine (D-amphetamine) and phenytoin, to positively or negatively affect the functional recovery of the cerebral cortex following excitotoxic injury. METHODS: Previous work from the same laboratory has demonstrated reorganization of whisker functional responses (WFRs) in the rat barrel cortex after excitotoxic lesions were created with kainic acid (KA). In the present study, WFRs were mapped using intrinsic optical signal imaging before and 9 days after creation of the KA lesions. During the post-lesion survival period, animals were either treated with intraperitoneal D-amphetamine, phenytoin, or saline or received no treatment. Following the survival period, WFRs were again measured and compared with prelesion data. RESULTS: The findings suggest that KA lesions cause increases in WFR areas when compared with controls. Treatment with D-amphetamine further increased the WFR area (p < 0.05) while phenytoin-treated rats showed decreases in WFR areas. There was also a statistically significant difference (p < 0.05) between the D-amphetamine and phenytoin groups. CONCLUSIONS: These results show that 2 commonly used drugs, D-amphetamine and phenytoin, have opposite effects in the functional recovery/plasticity of injured cerebral cortex. The authors' findings emphasize the complex nature of the cortical response to injury and have implications for understanding the biology of the effects of different medications on eventual functional brain recovery.
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Anticonvulsivantes/farmacología , Lesiones Encefálicas/fisiopatología , Estimulantes del Sistema Nervioso Central/farmacología , Dextroanfetamina/farmacología , Plasticidad Neuronal/efectos de los fármacos , Fenitoína/farmacología , Animales , Anticonvulsivantes/uso terapéutico , Lesiones Encefálicas/tratamiento farmacológico , Lesiones Encefálicas/etiología , Estimulantes del Sistema Nervioso Central/uso terapéutico , Corteza Cerebral/efectos de los fármacos , Corteza Cerebral/fisiopatología , Dextroanfetamina/uso terapéutico , Ácido Kaínico , Fenitoína/uso terapéutico , Ratas , Ratas Sprague-Dawley , Recuperación de la Función/efectos de los fármacos , Recuperación de la Función/fisiología , Factores de Tiempo , Vibrisas/efectos de los fármacos , Vibrisas/fisiologíaRESUMEN
OBJECT: The purpose of this study was to examine the results of using Gamma Knife surgery (GKS) for brain metastases from classically radioresistant malignancies. METHODS: The authors retrospectively reviewed the records of 76 patients with melanoma (50 patients), renal cell carcinoma (RCC; 23 patients), or sarcoma (3 patients) who underwent GKS between August 1998 and July 2007. Overall patient survival, intracranial progression, and local progression of individual lesions were analyzed. RESULTS: The median age of the patients was 57 years (range 18-85 years) and median Karnofsky Performance Scale (KPS) score was 80 (range 20-100). Sixty-two patients (81.6%) had uncontrolled extracranial disease. A total of 303 intracranial lesions (average 3.97 per patient, range 1-27 lesions) were treated using GKS. More than 3 lesions were treated in 30 patients (39.5%). Median GKS tumor margin dose was 18 Gy (range 8-30 Gy). Thirty-seven patients (48.7%) underwent whole brain radiation therapy. The actuarial 12-month rate for freedom from local progression for individual lesions was 77.7% and was significantly higher for RCC compared with melanoma (93.6 vs 63.0%; p = 0.001). The percentage of coverage of the prescribed dose to target volume was the only treatment-related variable associated with local control: 12-month actuarial rate of freedom from local progression was 71.4% for lesions receiving >or= 90% coverage versus 0.0% for lesions receiving < 90% (p = 0.00048). Median overall survival was 5.1 months after GKS and 8.4 months after the discovery of brain metastases. Univariate analysis revealed that KPS score (p = 0.000004), recursive partitioning analysis class (p = 0.00043), and single metastases (p = 0.028), but not more than 3 metastases, to be prognostic factors of overall survival. The KPS score remained significant after multivariate analysis. Overall survival for patients with a KPS score >or= 70 was 7.1 months compared with 1.3 months for a KPS score
Asunto(s)
Neoplasias Encefálicas/cirugía , Carcinoma de Células Renales/cirugía , Melanoma/cirugía , Radiocirugia , Sarcoma/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Encefálicas/mortalidad , Neoplasias Encefálicas/secundario , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/secundario , Estudios de Cohortes , Irradiación Craneana , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Neoplasias Renales/terapia , Melanoma/mortalidad , Melanoma/secundario , Persona de Mediana Edad , Dosificación Radioterapéutica , Radioterapia Adyuvante , Estudios Retrospectivos , Sarcoma/mortalidad , Sarcoma/secundario , Tasa de Supervivencia , Adulto JovenRESUMEN
Although nude mice are not truly hairless, they demonstrate abnormal hair structure and growth patterns, which are related to their genetic state. Whereas wild-type mice are born with visible vibrissae, nude mice are distinguishable at birth by the lack of visible vibrissae, which do not appear until approximately postnatal day 6. Additionally, adult nude mice have abnormal whisker cycling patterns in which structurally normal whisker follicles produce fragile whiskers which break or fallout leaving follicles whiskerless for several days before a fine replacement whisker appears and develops. The current study shows that despite these abnormal periods of whisker deprivation, the barrel cortex of nude mice develops a normal structural appearance viewed with cytochrome oxidase staining. Additionally, intrinsic optical imaging studies of barrel cortex responses to single whisker stimulation do not appear altered from normal despite periodic loss of adjacent whiskers.
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Ratones Pelados/fisiología , Ratones Desnudos/fisiología , Vibrisas/inervación , Envejecimiento , Animales , Complejo IV de Transporte de Electrones/análisis , Cabello/enzimología , Cabello/crecimiento & desarrollo , Ratones , Mutación , Valores de ReferenciaRESUMEN
OBJECT: The purpose of this study was to assess the efficacy of Gamma Knife surgery (GKS) in treating patients with trigeminal neuralgia (TN). Preliminary results of this study were previously reported. The updated results are reported in this paper. METHODS: Ninety seven patients with TN refractory to medical or surgical management underwent GKS between September 1998 and October 2005. Fifteen patients had multiple sclerosis (MS). The radiation dose was escalated from 70 to 99 Gy. The Barrow Neurological Institute Pain Scale (BNIPS) was used to assess pain before and after GKS. Eighty-four patients were available for evaluation with a mean follow up of 8.9 months. The overall response and complete response rates were 70.2% and 36.9%, respectively. At 12 months, there was a greater improvement in BNIPS scores for patients who were treated with two isocenters compared with those treated with a single isocenter. The mean percentage of pain decrease was 56.26% compared with 11.53% (p < 0.001). Patients treated with two isocenters rather than one and patients receiving greater than 85 Gy compared with lower doses had a longer duration of response. Only nine patients (11%) had mild numbness attributable to the GKS. Five of the nine patients experienced complete resolution of facial numbness on follow up. Patients with MS have a shorter duration of response compared with those without MS (p = 0.35). CONCLUSIONS: These updated results show that GKS continues to be an effective therapy for TN. It appears there is an enhanced response with doses 85 Gy or more and with two isocenters without increased complications.
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Dolor/prevención & control , Radiocirugia/métodos , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Relación Dosis-Respuesta en la Radiación , Humanos , Persona de Mediana Edad , Esclerosis Múltiple/complicaciones , Dolor/etiología , Dolor/patología , Dosificación Radioterapéutica , Estudios Retrospectivos , Resultado del Tratamiento , Neuralgia del Trigémino/etiología , Neuralgia del Trigémino/patología , Adulto JovenRESUMEN
STUDY DESIGN: Case report with review of the literature. OBJECTIVE: Symptomatic spinal cord herniation through ventral aspect of dura is frequently misdiagnosed because this condition is rare. The most frequent misdiagnosis was that of dorsal arachnoid cyst. The purpose of this article is to provide insight on clinical presentation, diagnosis, and surgical treatment of this entity. Results of our cases were compared with that of the reported literature. SUMMARY OF BACKGROUND DATA: Eighty-six cases reported in the literature were reviewed and data are presented in this article. METHODS: We had 3 patients diagnosed with spinal cord herniation through the ventral aspect of the dural sac. All 3 cases were misdiagnosed initially and later successfully operated. The dura was repaired primarily with suture in 1 case and with surgical graft in the other 2 cases. RESULTS: Reduction of spinal cord herniation reverses some of the signs and symptoms that have been present for years. Two of our patients had remarkable recovery in motor strength and bladder function. The third patient improved but remained with residual myelopathy. CONCLUSION: Ventral herniation of the thoracic spinal cord is a partially treatable cause of myelopathy, when recognized promptly and treated surgically. Recognizing this infrequent cause of myelopathy prevents misdiagnosis. Delay in diagnosis may impair recovery at a later date.
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Errores Diagnósticos , Hernia/diagnóstico , Herniorrafia , Enfermedades de la Médula Espinal/diagnóstico , Enfermedades de la Médula Espinal/cirugía , Adulto , Femenino , Hernia/complicaciones , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Debilidad Muscular/etiología , Debilidad Muscular/fisiopatología , Músculo Esquelético/fisiopatología , Mielografía , Recuperación de la Función , Enfermedades de la Médula Espinal/complicaciones , Vértebras Torácicas , Tomografía Computarizada por Rayos X , Vejiga Urinaria/fisiopatología , Incontinencia Urinaria/etiología , Incontinencia Urinaria/fisiopatologíaRESUMEN
Digital and print brain atlases have been used with success to help in the planning of neurosurgical interventions. In this paper, a technique presented for the creation of a brain atlas of the basal ganglia and the thalamus derived from serial histological data. Photographs of coronal histological sections were digitized and anatomical structures were manually segmented. A slice-to-slice nonlinear registration technique was used to correct for spatial distortions introduced into the histological data set at the time of acquisition. Since the histological data were acquired without any anatomical reference (e.g., block-face imaging, post-mortem MRI), this registration technique was optimized to use an error metric which calculates a nonlinear transformation minimizing the mean distance between the segmented contours between adjacent pairs of slices in the data set. A voxel-by-voxel intensity correction field was also estimated for each slice to correct for lighting and staining inhomogeneity. The reconstructed three-dimensional (3D) histological volume can be viewed in transverse and sagittal directions in addition to the original coronal. Nonlinear transformations used to correct for spatial distortions of the histological data were applied to the segmented structure contours. These contours were then tessellated to create three-dimensional geometric objects representing the different anatomic regions in register with the histological volumes. This yields two alternate representations (one histological and one geometric) of the atlas. To register the atlas to a standard reference MR volume created from the average of 27 T1-weighted MR volumes, a pseudo-MRI was created by setting the intensity of each anatomical region defined in the geometric atlas to match the intensity of the corresponding region of the reference MR volume. This allowed the estimation of a 3D nonlinear transformation using a correlation based registration scheme to fit the atlas to the reference MRI. The result of this procedure is a contiguous 3D histological volume, a set of 3D objects defining the basal ganglia and thalamus, both of which are registered to a standard MRI data set, for use for neurosurgical planning.
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Encéfalo/anatomía & histología , Procedimientos Neuroquirúrgicos/métodos , Algoritmos , Ganglios Basales/anatomía & histología , Encéfalo/cirugía , Interpretación Estadística de Datos , Bases de Datos Factuales , Humanos , Procesamiento de Imagen Asistido por Computador , Dinámicas no Lineales , Programas Informáticos , Técnicas Estereotáxicas , Tálamo/anatomía & histologíaRESUMEN
OBJECT: The authors sought to evaluate the initial response of trigeminal neuralgia (TN) to gamma knife surgery (GKS) based on the number of shots delivered and radiation dose. METHODS: Between September 1998 and September 2003, some 63 patients with TN refractory to medical or surgical management underwent GKS at Upstate Medical University. Ten patients had multiple sclerosis and 25 patients had undergone prior invasive treatment. Gamma knife surgery was delivered to the trigeminal nerve root entry zone in one shot in 27 patients or two shots in 36 patients. The radiation dose was escalated to less than or equal to 80 Gy in 20 patients, 85 Gy in 21 patients, and greater than or equal to 90 Gy in 22 patients. Pain before and after GKS was assessed using the Barrow Neurological Institute Pain Scale and the improvement score was analyzed as a function of dose grouping and number of shots. Sixty patients were available for evaluation, with an initial overall and complete response rate of 90% and 27%, respectively. There was a greater improvement score for patients who were treated with two shots compared with one shot, mean 2.83 compared with 1.72 (p < 0.001). There was an increased improvement in score at each dose escalation level: less than or equal to 80 Gy (p = 0.017), 85 Gy (p < 0.001), and greater than or equal to 90 Gy (p < 0.001). Linear regression analysis also indicated that there was a greater response with an increased dose (p = 0.021). Patients treated with two shots were more likely to receive a higher dose (p < 0.001). There were no severe complications. Five patients developed mild facial numbness. CONCLUSIONS: Gamma knife surgery is an effective therapy for TN. Initial response rates appear to correlate with the number of shots and dose.
Asunto(s)
Radiocirugia/instrumentación , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Relación Dosis-Respuesta en la Radiación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dosis de Radiación , Índice de Severidad de la Enfermedad , Neuralgia del Trigémino/diagnósticoRESUMEN
BACKGROUND: Activated eosinophils can be identified by electron microscopy (EM) Previous studies have shown EM evidence of eosinophil activation in a variety of gastrointestinal conditions associated with inflammation. The purpose of this study was to evaluate the activation state by EM of duodenal mucosal eosinophils in children who presented with dyspepsia and to determine if eosinophils are activated in patients with normal eosinophil counts on routine histology. METHODS: Twenty patients (ages 7-15 years) with dyspepsia were evaluated. All had normal gross endoscopies and was excluded. Each patient had two endoscopic forceps biopsies taken from both the duodenal bulb (DB) and the second portion of the duodenum (DS) for routine histology to determine eosinophil counts. Two additional biopsies were taken from the adjacent mucosa of each site for EM evaluation. The eosinophil activation state was determined for each specimen and a degranulation index was calculated for DB specimens. RESULTS: On routine histology, peak eosinophil counts were greater than or equal to 20 per hpf in three patients, 11 to 19 per hpf in 12 patients, and less than or equal to 10 per hpf in 5 patients. All patients showed evidence of EM activation on DB specimens and 95% showed activation on DS specimens. The mean degranulation index was 50.5 + 12.0% with 65% of specimens revealing moderate (20 - 60%) degranulation and 30% of specimens revealing extensive (greater than 60%) degranulation. CONCLUSIONS: Eosinophils present in the duodenal mucosa of children with dyspepsia are activated in a significant proportion of patients, even in those with normal eosinophil counts. The degree of degranulation is similar to that seen in other conditions where eosinophils have a pathogenic role.
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Duodeno/patología , Dispepsia/patología , Eosinófilos/patología , Mucosa Intestinal/patología , Adolescente , Biopsia , Niño , Duodeno/ultraestructura , Eosinófilos/ultraestructura , Femenino , Humanos , Mucosa Intestinal/ultraestructura , Masculino , Microscopía ElectrónicaRESUMEN
This study investigated the effect of hyperoxia on sensorimotorcortical activity resulting from electrical stimulation of the median nerve, using functional magnetic resonance imaging (fMRI). Nine volunteers underwent stimulation at 5 and 100 Hz while breathing 21% FIO(2) (fraction of inspired oxygen) or 100% FIO(2). fMRI data were correlated with a stimulus predictor curve, transformed into Talairach space and averaged by group. Normoxic (21% FIO(2)) and hyperoxic (100% FIO(2)) sensorimotor activation volumes were compared using Student's t-test. There were no significant differences between the primary somatosensory/primary motor/Brodmann area 40 (SI/MI/Ba40) and secondary somatosensory cortex (SII) activation volumes for normoxia and hyperoxia. (P>0.05). There was no difference between SI/MI/Ba40 and SII activations at 5 and 100 Hz. In contrast to results previously reported for primary visual cortex (V1), hyperoxia did not enhance sensorimotor cortical activation in area SI/MI/Ba40 or SII. These results indicate that there is regional heterogeneity of the fMRI response to hyperoxia in the cerebral cortex.
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Vías Aferentes/fisiología , Potenciales Evocados Somatosensoriales/fisiología , Hiperoxia/fisiopatología , Nervio Mediano/fisiología , Conducción Nerviosa/fisiología , Corteza Somatosensorial/fisiología , Adulto , Mapeo Encefálico , Estimulación Eléctrica , Femenino , Lateralidad Funcional/fisiología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana EdadRESUMEN
A primary spindle cell sarcoma of the sella turcica in a patient without a history of radiation treatment is a very rare occurrence. Only one other case has been reported to date, with local recurrence 7 months after the patient underwent subtotal resection and stereotactic radiosurgery of the tumor. The authors present a case of spindle cell sarcoma of the sella turcica successfully treated by surgery, external-beam radiotherapy, and gamma knife radiosurgery. After 24 months of follow up, the patient continues to show no evidence of disease.
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Neoplasias Óseas/cirugía , Radiocirugia , Sarcoma/cirugía , Silla Turca/cirugía , Neoplasias Óseas/radioterapia , Terapia Combinada , Femenino , Humanos , Persona de Mediana Edad , Sarcoma/radioterapiaRESUMEN
Prior work has indicated the existence of a major spinal cord pathway made up of lamina I cell axons ascending in the dorsolateral funiculus in both rat and cat. In cat, a portion of this lamina I dorsolateral funiculus pathway terminates in the thalamus. The purpose of this report is to demonstrate that a similar dorsolateral spinothalamic tract exists in macaque monkey. Retrograde transport of horseradish peroxidase, injected into the somatosensory thalamus of monkeys, was used to identify the cells of origin of the spinothalamic tract in the cervical and lumbar enlargements. In order to determine the funicular courses of the axons contributing to the spinothalamic pathway, thalamic injections of horseradish peroxidase were combined with ipsilateral ventral or dorsolateral thoracic spinal cord lesions. The results indicate that in macaque monkey many lamina I cell axons ascend to the thalamus in the dorsolateral funiculus, contralateral to their parent cells. Some lamina I cell axons as well as the majority of axons of spinothalamic cells located in deeper laminae ascend in the contralateral ventral quadrant to terminate in the thalamus. The existence in macaque of a dorsolateral spinothalamic pathway comprised of lamina I cell axons strongly implies the presence of a similar pathway in humans and has important implications regarding the mechanisms underlying both clinical and experimental nociception.