Trigeminal neuralgia caused by vertebrobasilar dolichoectasia is a rare condition. It is characterized by paroxysmal hemifacial pain which is lancinating in type mostly refractory to medical management. This is a report of trigeminal neuralgia secondary to vertebral dolicholectasia refractory to medical management treated with cyber knife stereotactic radiosurgery to the dose of 66 Gy in single fraction to the proximal nerve root. Pain relief was achieved immediately after the treatment and with a follow up period of 2 years, patient is pain free. Cyberknife assisted radiosurgery is relatively safe in delivering high ablative doses with precise conformality to small target regions like proximal nerve root entry of trigeminal nerve with no major toxicities and achieving early pain relief. It is an outpatient and non-invasive procedure. It can be used as a definite treatment modality for trigeminal neuralgia induced by vertebrobasilar dolichoectasia.
We sought to determine whether specific taxa in the communities of the C57BL/6J mouse intestinal microbiome were associated with survival after the LD 50/30 dose of total body irradiation (TBI), and if administration of a second-generation probiotic producing anti-inflammatory Interleukin-22 (IL-22) mitigated Gastrointestinal Syndrome inducing doses of total body irradiation (TBI). Materials/Methods: Female C57BL/6J mice were irradiated to LD 50/30 9.25 Gy TBI, or 19.75 Gy whole abdominal irradiation, and evaluated for primary endpoint of survival and secondary endpoint of expression of inflammatory proteins and bone marrow CFU-GEMMs per 10 4 cells. Daily collected fecal samples were analyzed for 16sRNA associated with 15 major taxa in the intestinal microbiome. Second-generation probiotic Lactobacillus reuteri or Escherichia-coli producing IL-22 (LR-IL-22 or E. coli-IL-22, respectively) was administered to subgroups by gavage at 24 hours after irradiation. The results were compared to subcutaneous administration of IL-22 (n Z 12). Results: Thirty-day TBI survivors of 9.25 Gy had at day 14 a predictive increased relative abundance of Lactobacillus, Roseburia, and Akkermansia, compared to other taxa, as did radiation mitigator treated (G-CSF or JP4-039) mice. Administration of LR-IL-22 at 24 hours after irradiation increased survival (p Z 0.0144), as did E. coli-IL-22. GFP-IL-22 fusion protein producing probiotics showed uptake in intestinal villi at 2 h after gavage and clearance by day 5. At 24 hrs. after 9.25 Gy TBI, mice with 4 antibiotic-cleared intestinal microbiomes (5 weeks administration in drinking water of vancomycin, neomycin trisulfate, metronidazole, and ampicillin) had increased survival when treated with E. coli-IL-22, (p < 0.0001). On day 5 after 9.25 Gy TBI, the intestine and bone marrow were isolated. Luminex assay showed significantly decreased inflammatory proteins in mice gavaged with LR-IL-22, and bone marrow had significantly increased CFU-GEMMs per 10 4 cells compared to 9.25 Gy only (15.1 AE 1.1 and 9.1 AE 1.5, respectively, p Z 0.0351). Whole abdomen irradiation to 19.75 Gy followed by gavage at 24 hrs. of LR-IL-22, or E. coli-IL-22 significantly increased survival (p Z 0.0138, 0.0473). Conclusion: These data indicate that the relative abundance of specific taxa in the intestinal microbiome correlates with survival after total body irradiation. Furthermore, gavage of LR-IL-22 improves survival after GI Syndrome inducing doses of irradiation. Elucidation of the molecular mechanism of interaction of pro-survival microbiome communities with intestinal stem cells and regenerating crypts should identify new targets for intestinal radiation protection and mitigation.
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.
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