OBJECTIVE The authors’ objective was to examine the safety and efficacy of salvage intracranial cesium-131 brachytherapy in combination with resection of recurrent brain tumors. METHODS The authors conducted a retrospective chart review of consecutive patients treated with intraoperative intracranial cesium-131 brachytherapy at a single institution. Permanent suture-stranded cesium-131 seeds were implanted in the resection cavity after maximal safe tumor resection. The primary outcomes of interest were local, locoregional (within 1 cm), and intracranial control, as well as rates of overall survival (OS), neurological death, symptomatic adverse radiation effects (AREs), and surgical complication rate graded according to Common Terminology Criteria for Adverse Events version 5.0. RESULTS Between 2016 and 2020, 36 patients received 40 consecutive cesium-131 implants for 42 recurrent brain tumors and received imaging follow-up for a median (interquartile range [IQR]) of 17.0 (12.7–25.9) months. Twenty patients (55.6%) with 22 implants were treated for recurrent brain metastasis, 12 patients (33.3%) with 16 implants were treated for recurrent atypical (n = 7) or anaplastic (n = 5) meningioma, and 4 patients (11.1%) were treated for other recurrent primary brain neoplasms. All except 1 tumor (97.6%) had received prior radiotherapy, including 20 (47.6%) that underwent 2 or more prior radiotherapy treatments and 23 (54.8%) that underwent prior resection. The median (IQR) tumor size was 3.0 (2.3–3.7) cm, and 17 lesions (40.5%) had radiographic evidence of ARE prior to salvage therapy. Actuarial 1-year local/locoregional/intracranial control rates for the whole cohort and patients with metastases and meningiomas were 91.6%/83.4%/47.9%, 88.8%/84.4%/45.4%, and 100%/83.9%/46.4%, respectively. No cases of local recurrence of any histology (0 of 27) occurred after gross-total resection (p = 0.012, log-rank test). The 1-year OS rates for the whole cohort and patients with metastases and meningiomas were 82.7%, 79.1%, and 91.7%, respectively, and the median (IQR) survival of all patients was 26.7 (15.6–36.4) months. Seven patients (19.4%) experienced neurological death from progressive intracranial disease (7 of 14 total deaths [50%]), 5 (13.9%) of whom died of leptomeningeal disease. Symptomatic AREs were observed in 9.5% of resection cavities (n = 4), of which 1 (2.4%) was grade 3 in severity. The surgical complication rate was 16.7% (n = 7); 4 (9.5%) of these patients had grade 3 or higher complications, including 1 patient (2.4%) who died perioperatively. CONCLUSIONS Cesium-131 brachytherapy resulted in good local control and acceptable rates of symptomatic AREs and surgical complications in this heavily pretreated cohort, and it may be a reasonable salvage adjuvant treatment for this patient population.
INTRODUCTION Vestibular schwannomas (VS) can cause significant morbidity from cranial neuropathies and mass effect. Broad molecular differences have been described for intracranial versus spinal axis schwannomas, but little is known about the molecular heterogeneity of VS or predictors of recurrence. METHODS A total of 66 sporadic VS from 59 consecutive patients with available tissue who underwent initial resection (44), resection for recurrence after prior surgery (5), resection for recurrence after prior stereotactic radiosurgery (SRS) (11), or resection after both prior surgery and prior SRS (6) at a single institution from 2003 to 2017 were profiled using 850 K DNA methylation arrays (median follow-up: 4.2 yr, median volumetric resection: 91%). A total of 24 VS were further characterized using RNA sequencing. Molecular subtyping was performed using differential-DNA methylation analysis and validated using transcriptomic data. Preoperative magnetic resonance imaging (MRI) studies were centrally reviewed by a board-certified neuro-radiologist. RESULTS NA methylation profiling revealed 2 novel subgroups of VS, delineated by enrichment of neural crest genes (31 tumors) or immune genes (35 tumors). Neural crest-enriched VS were more likely to show reduced diffusion on MRI (P < .01), while immune-enriched VS were more likely to show cystic changes (P < .05), mass effect (P < .01), and edema (P < .05). Immune-enriched VS were significantly more likely to be adherent to the brainstem and left as residual at the time of resection. A total of 15 immune-enriched VS (43%) had prior SRS, while only 2 neural crest-enriched VS (6%) had prior SRS (P < .001). Hypomethylation of G protein-coupled estrogen receptor 1 (GPER) promoter was prognostic for local failure in multivariate regression irrespective of primary treatment modality (P < .0001). CONCLUSION VS are comprised of 2 molecular subgroups characterized by differential enrichment of neural crest or immune genes. VS treated with prior SRS are associated with immune-enrichment. GPER promoter hypomethylation is prognostic for VS recurrence. These data illuminate the biology of VS and shed light on potential molecular therapies.
BACKGROUND Although tumor boards are well-established for coordinating care of patients with cancer in the outpatient setting, few studies have evaluated interventions for improving consultative care coordination for hospitalized patients. This study evaluated the hypothesis that implementation of an inpatient co-rounding model of care including medical-, neuro-, and radiation-oncology consult teams would improve the alignment of recommendations from these oncologic services, as perceived by primary teams. METHODS A co-rounding model was implemented in September 2021 for hospitalized patients with cancer at a tertiary medical center. The oncologic consulting services met virtually twice weekly to discuss patient care. Providers from the most common primary services for patients with cancer, internal medicine (IM) and neurosurgery, were surveyed via institutional email listservs. The survey included Likert-type questions about the alignment of recommendations across services and open-ended questions for feedback on collaboration among these services. Pre-intervention surveys were distributed, and post-intervention surveys were distributed 9 months later. Wilcoxon rank-sum tests were used to compare responses pre- and post-intervention. RESULTS At each session, a median of 6 providers attended (range, 4-8 providers), and a median of 6 patients were discussed (range, 4-8 patients). Of the 331 providers surveyed, there were 119 (36%) respondents pre-intervention and 34 (10%) respondents post-intervention. The 132 unique respondents comprised 68 (52%) IM attending physicians, 48 (36%) IM resident physicians, 6 (5%) neurosurgery advanced practice providers, 6 (5%) neurosurgery attendings, and 4 (3%) neurosurgery residents. Post-intervention, respondents were significantly more likely to perceive alignment in oncologic consultant recommendations (67% strongly agree) compared to pre-intervention (23% strongly agree, p<0.01). CONCLUSIONS A novel inpatient co-rounding model was successfully implemented between medical-, neuro-, and radiation-oncology. Primary teams perceived greater alignment in recommendations among these consulting services after implementation. Future directions include evaluation of the impact of this model on patient outcomes.
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