Five independent predictors of survival were identified: age, Karnofsky Performance Scale (KPS) score, extent of resection, and the degree of necrosis and enhancement on preoperative MR imaging studies. A significant survival advantage was associated with resection of 98% or more of the tumor volume (median survival 13 months, 95% confidence interval [CI] 11.4-14.6 months), compared with 8.8 months (95% CI 7.4-10.2 months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0 to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed significantly longer survival in patients with lower scores (1-3) who underwent aggressive resections, and a trend toward slightly longer survival was found in patients with higher scores (4-5). Gross-total tumor resection is associated with longer survival in patients with GBM, especially when other predictive variables are favorable.

SUMMARYBackgroundAfter brain metastasis resection, whole-brain radiation therapy (WBRT) decreases local recurrence but may cause cognitive decline. We performed this study to determine if stereotactic radiosurgery (SRS) to the surgical cavity improved local tumor tumor-free recurrence rates compared to surgical resection alone as an alternative to the need for immediate WBRT.MethodsThe main entry criteria for the study included patients >3 years of age, with a Karnofsky Performance Score ≥ 70, who were able to undergo an MRI scan and who had a complete resection of 1–3 brain metastases (the maximum diameter of the resection cavity had to be ≤4cm). Patients were assigned randomly to either SRS treatment of the resection cavity (within 30 days of surgery) or observation (OBS). Patients were stratified by histology, tumor size, and number of metastases. Patients were recruited at a single tertiary cancer center. The primary endpoint was time to local recurrence in the resection cavity assessed by blinded central review of brain MRI scans in the intention-to-treat population. The trial was registered at clinicaltrials.gov (Trial NCT00950001, status: closed to new participants).FindingsBetween 8/13/2009 and 2/16/2016, 132 patients were randomized to OBS (N=68) or SRS (N=64), with 128 patients available for analysis. We stratified by metastasis size (maximum diameter of ≥3 cm vs. <3 cm), histology (melanoma vs. other), and number of metastases (one vs. two or three). The 12-month local tumor recurrence-free rate was 43% (OBS) (95% CI 31%–59%) and 72% (SRS) (95% CI 60%–87%) (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.24–0.88, p=0.015).InterpretationThis prospective randomized trial of patients undergoing surgical resection for 1–3 brain metastases indicates that SRS administered to the resection cavity significantly lowers local recurrence compared to observation alone. Thus, the use of SRS after brain metastasis resection is an alternative to WBRT.

To the best of our knowledge, this is the largest US series to date of patients with malignant tumors of the sinonasal tract treated with endoscopic resection. Our results suggest that, in well-selected patients and with appropriate use of adjuvant therapy, endoscopic resection of sinonasal cancer results in acceptable oncologic outcomes.

Defining a tumor as a PEM is dependent on the tumor's relation to the dura mater and the extent and direction of its growth. Classification of PEMs as calvarial or extracalvarial and as convexity or skull base lesions correlates well with clinical outcome.

Despite recent advances in surgery of the cavernous sinus, meningiomas in that area offer a formidable challenge. The rationale for aggressive surgical removal of cavernous sinus meningiomas is based on the presumption that the extent of removal is inversely related to the rate of recurrence. Over the past 10 years, 41 patients with histologically benign meningiomas involving the cavernous sinus underwent aggressive surgery. Total removal, as confirmed by intraoperative inspection and postoperative radiological studies, was achieved in 31 patients (76%). Twelve patients have been followed for more than 5 years; 10 underwent total tumor removal and only one of these experienced recurrence (5 years after surgery). The other two patients underwent subtotal removal and had symptomatic and radiological evidence of regrowth 3 and 4 years after surgery. Pre-existing cranial nerve deficits improved in only 14% of the patients, remained unchanged in 80%, and worsened permanently in 6%. Seven patients experienced a total of 10 new cranial nerve deficits, four of which involved the nerves subserving ocular motor function. Extraocular muscle function did not worsen in the 25 patients with a seeing eye ipsilateral to the tumor, and no instance of visual worsening occurred. Two patients died 4 months after surgery, one from severe delayed vasospasm and hypothalamic infarction and the other because of a myocardial infarction. Another patient died from a pulmonary embolus on the 9th postoperative day. There were three instances of cerebral ischemia; one was transient, lasting less than 24 hours, while two were related to injury of the middle cerebral artery and resulted in residual hemiplegia. Other complications included three cases of nonfatal pulmonary emboli, two cerebrospinal fluid leaks, and one instance each of exposure keratitis, acute hypothyroidism, and cerebral edema.