Intraventricular hemorrhage (IVH) is a relatively commonly encountered problem in neurosurgical practice. The underlying causes could include hypertension, arteriovenous malformations (AVM), angiomas, trauma, tumors, aneurysms and moyamoya disease. Truly idiopathic intraventricular aneurysms (IVA) are rare. A high index of suspicion needs to be maintained since, with the appropriate treatment, the outcome is generally good.We report the case of a 14-year-old boy who presented with sudden onset headache and vomiting. CT angiogram pointed to the possibility of an IVA. This was confirmed by MRI with three-dimensional constructive interference in steady state (CISS-3D) sequences and digital subtraction angiography. The patient underwent microsurgical excision of the aneurysm and is doing well on follow-up.Idiopathic IVA can present with IVH at any age. MRI with CISS-3D and MR angiography would be the imaging modality of choice since it can also rule out other causes of intraventricular bleeding such as tumors and AVM. These lesions could be managed effectively by microsurgical excision/clipping. The necessity of investigating every patient who presents with IVH is debatable.
Purpose/Objective(s): Utilization of stereotactic radiotherapy in the management of renal cell carcinoma is increasing internationally (Siva et al, Nat Rev Urol, 2017). Our objectives are to assess the efficacy and safety of stereotactic radiotherapy for metastatic renal cell carcinoma (RCC). We hypothesized that local control is >85% and significant toxicity is <15%. Materials/Methods: A PICOS/PRISMA/MOOSE selection protocol was utilized to select studies published between 1998 and 2019. The primary outcome was 1-year local control (LC) and 1-year overall survival (OS); secondary outcome was incidence of any acute or late Common Terminology Criteria for Adverse Events (CTCAE) grade 3-4 toxicity. Each outcome was stratified by extra-or intracranial RCC involvement. Weighted random effects meta-analyses were conducted, where the Der-Simonian and Laird method was used to calculate between study variance for each of the primary and secondary outcomes. Heterogeneity was assessed using the I 2 statistic and Cochran's Q-Test. Publication bias was assessed using funnel plots and the Egger Test, where publication bias was considered absent if the p-value was < 0.05. Results: A total of 265 studies were initially screened. A total of 28 studies (27 retrospective, 1 prospective) from 8 countries, were included in the meta-analysis. There were a total of 1,602 mutually exclusive patients (679 extracranial/923 intracranial) and 3,892 lesions (1,159 extracranial/2,733 intracranial). The median patient age was 62 years (range: 55-56 years). The median treatment volume was 59.7 cc for extracranial lesions (interquartile range: 31.1-71.4) and 2.3 cc for intracranial lesions (interquartile range: 1.3 e 4.3). Under the random effects model, the summary effect size for 1-year LC was 89.1% (95% confidence interval [CI]: 83.6%-93.7%, I 2 Z71%) and 90.1% (95% CI: 83.5%-95.3%, I 2 Z74%) for extracranial and intracranial disease, respectively. For 1-year OS: 86.8% (95% CI: 62%-99.8%, I 2 Z95%) and 49.7% (95% CI: 41.1%-58.3%, I 2 Z74%) for extracranial and intracranial disease, respectively. The incidence of any grade 3-4 toxicity was 0.7% (95% CI: 0%-2.1%, I 2 Z0%) and 1.1% (95% CI: 0%-7.4%, I 2 Z53%) for extracranial and intracranial disease, respectively. There was no publication bias present for any of the outcomes (Egger Test: p>0.05), regardless of site. Conclusion: Stereotactic radiotherapy is safe and efficacious in the management of extracranial and intracranial RCC oligometastases, with LC at 90% and any significant toxicity at 1%. Patients with intracranial metastases have worse survival than those with extracranial disease, despite smaller treatment volumes. Further prospective studies are needed.
To investigate the tradeoff of esophageal treatment between real-time breath hold (BH) MR-guided radiotherapy (MRgRT), free breathing (FB) CT-based intensity modulated proton therapy (IMPT), and FB VMAT. We hypothesize that improved cardiopulmonary sparing would be achieved with BH MRgRT or FB IMPT compared to FB VMAT. Materials/Methods: We retrospectively evaluated differences in heart/lung dose and treatment plan conformality among 28 patients with distal esophageal cancer who were each treated with either IMPT (n Z 10), MRgRT on an MR-guided Linac (n Z 11), or VMAT (n Z 7). All were prescribed 50.4 Gy/28 fractions. IMPT and VMAT patients received a 4DCT simulation scan to quantify the internal target volume margin (ITV) for respiratory motion. MRgRT patients were simulated and treated in an inspiration BH with a 3 mm CTV to PTV margin. In lieu of a PTV margin for IMPT cases, robust optimization for range and setup uncertainty was performed on iCTV (i.e., CTV with respiratory ITV). RTOG plan quality metrics were used to evaluate target coverage (TC) (PTV V100%/PTV vol), homogeneity index (HI) (PTV D2%/ D98%), high dose conformity (PITV), low dose conformity (D2cm), and gradient (R50%). For all coverage metrics, the CTV was used. Results: Mean cardiac sparing among all patients between respective
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