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.

More complete brain cancer resection can prolong survival and delay recurrence. However, it is challenging to distinguish cancer from non-cancer tissues intraoperatively, especially at the transitional, infiltrative zones. This is especially critical in eloquent regions (e.g. speech and motor areas). This study tested the feasibility of label-free, quantitative optical coherence tomography (OCT) for differentiating cancer from non-cancer in human brain tissues. Fresh ex vivo human brain tissues were obtained from 32 patients with grades II-IV brain cancer and 5 patients with non-cancer brain pathologies. Based on volumetric OCT imaging data, pathologically confirmed brain cancer tissues (both high-grade and low-grade) had significantly lower optical attenuation values at both cancer core and infiltrated zones when compared with non-cancer white matter, and OCT achieved high sensitivity and specificity at an attenuation threshold of 5.5 mm-1 for brain cancer patients. We also used this attenuation threshold to confirm the intraoperative feasibility of performing in vivo OCT-guided surgery using a murine model harboring human brain cancer. Our OCT system was capable of processing and displaying a color-coded optical property map in real time at a rate of 110-215 frames per second, or 1.2-2.4 seconds for an 8-16 mm3 tissue volume, thus providing direct visual cues for cancer versus non-cancer areas. Our study demonstrates the translational and practical potential of OCT in differentiating cancer from non-cancer tissue. Its intraoperative use may facilitate safe and extensive resection of infiltrative brain cancers and consequently lead to improved outcomes when compared with current clinical standards.

Introduction. Surgery is first-line therapy for glioblastoma, and there is evidence that gross total resection is associated with improved survival. Gross total resection, however, is not always possible, and relationships among extent (percent) of resection (EOR), residual volume (RV), and survival are unknown. The goals were to evaluate whether there is an association between EOR and RV with survival and recurrence and to establish minimum EOR and maximum RV thresholds. Methods. Adult patients who underwent primary glioblastoma surgery from 2007 to 2011 were retrospectively reviewed. Three-dimensional volumetric tumor measurements were made. Multivariate proportional hazards regression analysis was used to evaluate the relationship between EOR and RV with survival and recurrence. Results. Of 259 patients, 203 (78%) died and 156 (60%) had tumor recurrence. The median survival and progression-free survival were 13.4 and 8.9 months, respectively. The median (interquartile range) pre-and postoperative tumor volumes were 32.2 (14.0-56.3) and 2.1 (0.0-7.9) cm 3 , respectively. EOR was independently associated with survival (hazard ratio [HR], 0.995; 95% confidence interval [CI]: 0.990-0.998; P ¼ .008) and recurrence (HR [95% CI], 0.992 [0.983-0.998], P ¼ .005). The minimum EOR threshold for survival (P ¼ .0006) and recurrence (P ¼ .005) was 70%. RV was also associated with survival (HR [95% CI], 1.019 [1.006-1.030], P ¼ .004) and recurrence (HR [95% CI], 1.024 [1.001-1.044], P ¼ .03). The maximum RV threshold for survival (P ¼ .01) and recurrence (P ¼ .01) was 5 cm 3. Conclusion. This study shows for the first time that both EOR and RV are significantly associated with survival and recurrence, where the thresholds are 70% and 5 cm 3 , respectively. These findings may help guide surgical and adjuvant therapies aimed at optimizing outcomes for glioblastoma patients.

PURPOSE Multimodal therapy is a well-established approach for the treatment of sinonasal undifferentiated carcinoma (SNUC); however, the optimal sequence of the various treatments modalities is yet to be determined. This study aimed to assess the role of induction chemotherapy (IC) in guiding definitive therapy in patients with SNUC. METHODS Ninety-five previously untreated patients diagnosed with SNUC and treated between 2001 and 2018 at The University of Texas MD Anderson Cancer Center were included in the analysis. Patients were treated with curative intent and received IC before definitive locoregional therapy. The primary end point was disease-specific survival (DSS). Secondary end points included overall and disease-free survival, disease recurrence, and organ preservation. RESULTS A total of 95 treatment-naïve patients were included in the analysis. For the entire cohort, the 5-years DSS probability was 59% (95% CI, 53% to 66%). In patients who had partial or complete response to IC, the 5-year DSS probabilities were 81% (95% CI, 69% to 88%) after treatment with definitive concurrent chemoradiotherapy (CRT) after IC and 54% (95% CI, 44% to 61%) after definitive surgery and postoperative radiotherapy or CRT after IC (log-rank P = .001). In patients who did not experience at least a partial response to IC, the 5-year DSS probabilities were 0% (95% CI, 0% to 4%) in patients who were treated with concurrent CRT after IC and 39% (95% CI, 30% to 46%) in patients who were treated with surgery plus radiotherapy or CRT (adjusted hazard ratio of 5.68 [95% CI, 2.89 to 9.36]). CONCLUSION In patients who achieve a favorable response to IC, definitive CRT results in improved survival compared with those who undergo definitive surgery. In patients who do not achieve a favorable response to IC, surgery when feasible seems to provide a better chance of disease control and improved survival.

A complete understanding of the series of events surrounding necrosis development in glioblastomas that is evidence-based is likely to provide targets for future therapies. On the basis of the potential mechanisms of development of necrosis described in this article, we postulate that effective therapies may have to be directed against the pathways that result in the formation of necrosis.

Object Because multiple anatomical compartments are involved, the surgical management of trigeminal schwannomas requires a spectrum of cranial base approaches. The endoscopic endonasal approach to Meckel's cave provides a minimal access corridor for surgery, but few reports have assessed outcomes of the procedure or provided guidelines for case selection. Methods A prospectively acquired database of 680 endoscopic endonasal cases was queried for trigeminal schwannoma cases. Clinical charts, radiographic images, and long-term outcomes were reviewed to determine outcome and success in removing tumor from each compartment traversed by the trigeminal nerve. Results Four patients had undergone endoscopic resection of trigeminal schwannomas via the transpterygoid approach (mean follow-up 37 months). All patients had disease within Meckel's cave, and 1 patient had extension into the posterior fossa. Gross-total resection was achieved in 3 patients whose tumors were purely extracranial. One patient with combined Meckel's cave and posterior fossa tumor had complete resection of the extracranial disease and 52% resection of the posterior fossa disease. One patient with posterior fossa disease experienced a sixth cranial nerve palsy in addition to a corneal keratopathy from worsened trigeminal neuropathy. There were no CSF leaks. Over the course of the study, 1 patient with subtotal resection required subsequent stereotactic radiosurgery for disease progression within the posterior fossa. Conclusions Endoscopic endonasal approaches appear to be well suited for trigeminal schwannomas restricted to Meckel's cave and/or extracranial segments of the nerve. Lateral transcranial skull base approaches should be considered for patients with posterior fossa disease. Further multiinstitutional studies will be necessary for adequate power to help determine relative indications between endoscopic and transcranial skull base approaches.

Study Design Observational cross-sectional study Objective Using data from the population-based cancer registries of the SEER program, we analyzed demographic features, tumor and treatment characteristics, as well as survival rates in patients with PMASC. Summary of Background Data Primary malignant astrocytomas of the spinal cord (PMASC) are a rare neoplasm and considered to carry the same dismal outcome as their cerebral counterparts. Our current knowledge is incomplete, and understanding the epidemiology, diagnosis and optimal treatment is still posing challenges. Methods The SEER data from 1973–2007 was reviewed for pathologically confirmed primary Anaplastic Astrocytomas (AA) and Glioblastomas (GB) of the spinal cord (C72.0). We compared the clinical features and outcomes of the cohort in uni- and multivariate fashion. Survival was calculated and compared using Kaplan-Meier curves and log-rank analysis. Results Our search criteria retrieved 135 patients diagnosed with PMASC. The median survival for PMASC was 13 months with 1, 2 and 5-year survival rates of 51.8%, 32.2% and 18.7%. Patient diagnosed with AA had a median survival time of 17 months versus 10 month in patients diagnosed with GB. Adult patients observed markedly prolonged survival compared to the pediatric group, with a 16 versus 9 months median survival, respectively. Multivariate analysis revealed age at diagnosis, pediatric and adult age groups, sex, tumor histology, and extent of resection as significant predictors of survival. Interestingly, outcomes did not significantly change throughout the last decades or by receiving radiotherapy. Conclusion Outcome for patients diagnosed with PMASC remains poor and presents an ongoing challenge for professionals in the field of neuro-spinal medicine and surgery. In our analyses AA, adult patients, males and patients undergoing radical resections were associated with increased survival. However, incidence of these lesions is low, hence building strong collaborative, interdisciplinary and multi-institutional study groups is necessary to define the optimal treatment of PMASC.

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