#srs for brain metastasis

[drvineetagoeloncologist]

Dr. Vineeta Goel is best known for providing solitary brain metastases treatment in north delhi an delhi ncr; you can get in touch with her for solitary brain metastases treatment in east delhi, solitary brain metastases treatment in west delhi.

[neurocirurgiabr]

Symptomatic radiation necrosis in brain metastasis patients treated with stereotactic radiosurgery and immunotherapy.

Symptomatic radiation necrosis in brain metastasis patients treated with stereotactic radiosurgery and immunotherapy.

Symptomatic radiation necrosis in brain metastasis patients treated with stereotactic radiosurgery and immunotherapy. Weingarten N, et al. Clin Neurol Neurosurg. 2019. Show full citation Abstract

OBJECTIVES: The association of symptomatic radiation necrosis (RN) with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs) in brain metastases patients has been incompletely…

[advaiton01]

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SRS for Brain Metastasis - Advaitoncology offers surgical oncology services, radiology services for cancer treatment in Ahmedabad Gujarat. We have certified and experienced pediatric oncologists and top oncologists in Ahmedabad. Visit and get best cancer care & treatment hospital in Ahmedabad Gujarat.

[myabhijitr]

Stereotactic Systems Market- Size, Share, Outlook, And Analysis 2018–2026

Stereotactic Systems are mostly used in minimally invasive surgical technique for precisely directing the tip of a delicate instrument or beam of radiation in three-dimensional coordinates to locate target part inside the body and to perform ablation, biopsy, lesion, injection, stimulation, implantation, radiosurgery (SRS), and others. Stereotaxic surgery is mostly used to locate lesions in the brain and deliver radiation therapy for the treatment of Parkinson’s disease.

Rapid innovation in minimally invasive surgery techniques is one of the major factors, which is expected to boost growth of the stereotactic systems market. For instance, in November 2018, Monteris Medical, published the favorable clinical data for its NeuroBlate Laser Ablation after Stereotactic Radiosurgery (LAASR) for patients with brain metastasis in the Journal of Neurosurgery. The NeuroBlate System is a minimally invasive, robotically controlled laser thermotherapy that uses MRI-guided laser light to ablate unwanted tissue in the brain where the lesion originates. Monteris is exclusively focused on advancing both LITT technology and clinical research to serve the unmet needs of neurosurgeons and their patients.

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Furthermore, in December 2017, the U.S. Food and Drug Administration approved GammaPod, new system of Xcision Medical Systems, LLC. GammaPod is a noninvasive stereotactic radiotherapy system intended for treating cancer in breast tissue.

Moreover, in March 2018, Sunway Medical Centre (SunMed), Malaysia’s multi-disciplinary Medical Centre, introduced Leksell Gamma Knife Icon (an advanced radiation machine, which was manufactured by Elekta AB). It is used for the treatment of various neurological disorders and brain conditions that require open brain surgery.

Based on region, North America is projected to gain major share in the stereotactic systems market, owing to expansion of various key players in this region. For instance, in March 2016, Monteris Medical, a privately held company, started developing innovative laser-based MRI-guided neuroablation tools and solutions in its new facility unit in Plymouth, Minnesota. Moreover, increasing prevalence of Parkinson's disease (PD) creates demand for stereotactic systems for treating the disease, which will in turn boost growth of the market.

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For instance, in March 2018, the Parkinson’s Foundation Prevalence Project estimated that about 60,000 Americans are diagnosed with PD each year. This number is predicted to rise to 1.2 million in upcoming years. The combined cost of Parkinson’s disease, including treatment, social security payments, and lost income from inability to work, is estimated to be nearly US$ 25 bn per year in the U.S. alone.

For instance, in October 2018, Asia Pacific Medical Technology Association (APACMed) in partnership with U.S.-based MedTech Innovator, launched MedTech Innovator Asia. The main objective of MedTech Innovator Asia is to accelerate the growth of the most promising medical device, digital health, and diagnostic startups in the Asia Pacific region.

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Key players in the stereotactic system market include Alliance HealthCare Services, Micromar Ind. e Com. LTDA, adeor Medical AG, Monteris Medical, Elekta AB., and inomed Medizintechnik GmbH.

[cbotella1]

Predictors of Local Control of Brain Metastasis TreatedWith Laser Interstitial Thermal Therapy

Predictors of Local Control of Brain Metastasis TreatedWith Laser Interstitial Thermal Therapy

Neurosurgery 87:112–122, 2020

Laser Interstitial Thermal Therapy (LITT) has been used to treat recurrent brain metastasis after stereotactic radiosurgery (SRS). Little is known about how best to assess the efficacy of treatment, specifically the ability of LITT to control local tumor progression post-SRS.

OBJECTIVE: To evaluate the predictive factors associated with local recurrence after LITT.

[juniperpublishersoa]

Juniper Publishers| A New Clinical Classification of Hilar Cholangiocarcinoma (Klatskin Tumor)

Journal of Surgery-JuniperPublishers

Introduction

Altemeir first described hepatic hilar cholangiocarcinoma in 1957 [1]. In 1965, a series of 13 cases of hepatic hilar cholangiocarcinoma was reported by Klatskin [2]. This tumor makes up about 60% of all cholangiocarcinoma. Anatomically, this tumor situates at special site, i.e. hilar biliary bifurcation within a limited small space, close to vessels (portal vein, hepatic artery) and liver (especially caudate lobe). Biologically, it usually grows slowly and locally, with submucosal infiltration (up to 1.6 cm from gross margin of the tumor), neurovascular infiltration and lymphnode metastasis, but less often with distance metastasis. Therapeutically, its resection usually is difficult, especially to obtain R0 resection, while it does not respond well with chemo-and/or radiational therapy. Local recurrence is high (>50%), leading treatment failure and poor outcome [3].When humans ingest the eggs of the tapeworm, embryos emerge from the eggs and penetrate the intestinal mucosa. From there the embryos are transported via the blood to various organs and get lodged in organs like liver (65 - 75% of all cases) and lungs (25 - 30% of all cases). In children the most common organ being lungs followed by liver. Other organs such as the spleen, heart and brain are affected rarely [4,5]. Bone and soft-tissue hydatid disease are rare form of presentation of hydatid disease and account for around 1 - 5% of all cases. The environment in muscles is toxic to the establishment and growth of the cestode because of the increased concentration of the lactic acid and the movement of the muscles. Most of the muscular hydatid disease are secondary to visceral involvement and primary muscular hydatid diseases is even rarer, with most common sites being the neck, trunk and roots of the limbs [6,7]. We report a rare case of a primary intramuscular hydatid cyst of femoral muscles in a man who presented as a mass in the right thigh, making diagnosis very difficult.Go to

Staging/Classification

Over years, there were a number of staging/classification system, including Bismuth/Corlette, Liver Cancer Study Group of Japan, MSKCC (Memorial Sloan Kettering Cancer Center), AJCC (American Joint Committee of Cancer), and most recently European HPBA (European Hepato-Pancreato-Biliary Association). The most well-known classification was from Dr. Henry Bisthmus (Figure 1) [4], who classified the tumor according to the anatomic locations:

Type 1 - tumor involves hepatic bile duct only;

Type 2 - tumor involves bile duct bifurcation;

Type 3a - tumor involves bile duct burfication and right hepatic bile duct;

Type 3b - tumor involves bile duct burfication and left hepatic bile duct;

Type 4 - tumor involves both sides of hepatic bile ducts. This system is used widely in clinical practice. It was based on anatomic level or involvment of the tumor to biliary tree. This does help in preparation of surgical plan. However, it does not describe the involvement status of vessels, status of liver parenchyma, metastasis and lymphnode. Therefore, it is not as helpful when liver resection and vascular resection/reconstruction are considered.

In 2000, the Liver Cancer Study Group of Japan proposed a classification according cancer growing pattern, mass forming, periductal infitration and intraductal growing (Figure 2) [5]. This was more about cancer biological behaviour, with better prognosis of mass forming and intraductal growing. Preoperatively, the information about this classification would unlikely be obtained in detail. Further more, there was no description about vascular involvement and liver lobar status. Therefore, the value of this classification in surgical assessment regarding resectability was limited.

MSKCC staging/classification took bile duct involvement, vascular involvement and liver atrophy into consideration (Table 1) [6]. It helps in preparation of liver resection in treatment of Klatskin tumor. However, this classification did not include lymphnode and metastasis status, and did not consider liver transplantation as option of treatment. The AJCC’s TNM classification based on tumor, lymphnodes involvemen and distance metastasis [7] (Table 2). TNM is often used for most of the cancer staging. However, it is mostly appropriate for postoperative pathological staging, as some information such as tumor invasion, lymphnode metastasis, may not be accurately assessed before surgery.

In 2011, an international working group based on a consensus from the European Hepato-Pancreato-Biliary Assoiation, published a new most complete staging/classification system [8] (Table 3) [16]. This is not only including information about bile duct, hepatic artery and portal vein, but also covering tumor biological growing form, liver resection related information such as liver volume, remnant volume and, background liver disease history. This system seems very complicated with some information not easily and accurately obtainable before resection.

Surgical management update

Original local resection of hilar cholangiocarcinoma (Klatskin tumor) had poor long term results with 5 year survival <7.3% [9]. In 1990’s, more and more studies showed R0 resection resulted longer survival. Klatskin tumor is found to have relatively low distance metastasis and high local recurrences. Therefore, combining radical choledochectomy with liver lobectomy was promoted, especially including right hemi- or right extended hemihepatectomy plus caudate lobe resection [10,11]. The 5 year survival rate increased to over 30-40%. However, postoperative morbidity and mortality were as high as 59% and 11%. In 2009, Chen XP et al. [12] however, published a paper on British Journal of Surgery, suggesting minor limited hepatectomy for patients whose cancers were not involving vascular structures might not be necessarily worse in outcome, with 5-yr survival rate of 34%, while the postoperative morbidity and mortality from a major extended resection were greatly avoided [12].Issue of vascular resection and reconstruction has been reviewed through a mega-analysis by Abass S and Sandrassi C [13]. There were 669 patients out of 2457 cases had vascular resection, 22-88% resected sample were found positive on pathology, 36-88% of patients achieved R0 resection while the morbidity and mortality were respectively 22-88% and 2-15%. Five year survival was 20-56%. In 2012, Jong MC et al. [14] reported a multi-institutional analysis of 305 cases [14], showing portal vein resection should be undertaken when necessary to extirpate all disease. Combined liver resection, extra-hepatice bile duct resection and portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma.Liver transplantation for treatment of cholangiocarcinoma has been attempted for more than twenty years. Before 2000, however, five year survival was only 28%. With neo-adjuvant therapy, the results were gradually improving. In 2005, Rea SR et al. [15] from Mayo Clinic with tedious strict preoperative selecting and treatment protocol [15]. The results was significantly better, with 1, 3, 5 year survival as 92%, 82% and 82%. Liver transplantation as a treatment option though in a small highlyselected group of patient, achieves R0 resection more readily without concerning about lobar atrophy, intrahepatic bile duct or vascular involvment.Go to

Proposal Of New Clinical Classification

Former staging/classifications did not take fully consideration of therapeutic process and are limited on description of cancer status related surgical management. Any final results of a cancer patient treatment is actually determined by three parts [15]:

patient’s systemic healthy with range of tolerance of therapeutic actions;

the cancer itself and its response to therapies; and

the therapies.

This new clinical classification is based on clinical therapeutic options according to patient’s condition and cancer status. As therapeutic technologies including neoadjuvant therapy, chemoradiation and transplantation, are continuously improving, with further advances in therapeutic technologies in the future, more vpatients will receive radical treatment with better final results. In order to take all present available therapeutic options into consideration, a new clinical therapeutic classification is here proposed (Table 4).

BD: Bile Duct; PV: Portal Vein; HA: Hepatic Artery; lap: Exploratory Laparotomy; LXT: Liver TransplantationThis relatively simple classification is to help in making clinical decisions regarding therapeutic purpose. The patients with Klatskin tumor are classified in 4 groups: resectable, marginally resectable, unresectable but transplantable and, unresectable and untransplantatable. Surgical treatment of hilar cholangiocarcinoma is not only depending on resection, but also on reconstruction. We could do as much resection as possible, as long as vascular and biliary reconstruction is achievable. Liver transplantation is useful when reconstruction becomes not possible. However, in order to achieve long-term good outcome with liver transplantation, liver transplantation could only be used in highly-selected patient group without distance metastasis, at present i.e. biologically less aggressive with 3-months neoadjuvant therapy with no progress and pathologically localized tumor with exploratory laparotomy -finding of no positive lymphnode.Go to

Conclusion

Advances in management of hilar cholangiocarcinoma (Klatskin Tumor) leads to a new clinical classification, which will facilitate in clinical therapeutic decision at present time.

[enzaime-blog]

What would you do

New Story has been published on https://enzaime.com/what-would-you-do/

What would you do

“Fox Chase was the answer to our prayers.”

Imagine being told you have an inoperable brain tumor with about 3 months to live. What would you do? In 2007, Teresa Palumbo had to face that dilemma. Luckily for Teresa, her husband knew what to do. Nicholas figured that if anyone could treat his wife, it would be the doctors at Fox Chase Cancer Center. He happened to be right.

If anyone could treat Teresa, it would be the doctors at Fox Chase Cancer Center.

The year before, Teresa was diagnosed and treated for breast cancer at a local community hospital. Her surgeon performed a lumpectomy on her left breast and removed 11 lymph nodes. After surgery, Teresa underwent courses of both chemotherapy and radiation to reduce the chance of recurrence.

Teresa, part of the “sandwich generation,” rises at 5:00 every morning to get to work as a kindergarten teacher, watches her grandchildren after school and cares for her mother, who lives with the Palumbos. “It’s never dull at our house,” said Teresa, who occasionally reads to relax.

“The doctors [at my community hospital] told me I had 3 months to live.”

One year later, Teresa went to another community hospital where she was diagnosed with a metastasis of her breast cancer to the brain. “The doctors told me I had 3 months to live. They said there was nothing they could do,” Teresa recalled.

Nicholas arranged for his wife to see the radiation oncology team at Fox Chase, who were able to treat Teresa’s tumors using sophisticated technology called stereotactic radiosurgery (SRS). This non-invasive procedure involves the precise delivery of a single, high dose of radiation.

“Fox Chase was the answer to our prayers,” said Teresa, who noted that everyone she met at Fox Chase was compassionate and professional.

Teresa responded very well to the treatment and finished by the fall of 2007. After a short recovery, Teresa resumed her full time teaching position at Our Lady of Grace in Penndel.

“I get so much pleasure from my students and I really missed them while I was out,” shared Teresa, who believes that her recovery was aided by the overwhelming support provided by her school faculty and through the “angelic power of children’s prayer.” Teresa also values “being able to help my daughter by babysitting her children. I wouldn’t trade it for the world.”

Teresa attends Mass at her church every day. “I feel that I escaped disaster and experienced a miracle by dodging this bullet,” Teresa mentioned. “Faith is very important with healing.” Teresa and her husband also visit regularly and pray at The Shrine of Saint Katherine Drexel.

“The doctors at Fox Chase gave us back Teresa’s life.”

Since her treatment, Teresa and Nicholas have received several calls from people diagnosed with brain tumors. “They are desperate for help, just like we were. We recommend Fox Chase to everyone who asks,” Nicholas said. “The doctors at Fox Chase gave us back Teresa’s life.”

[drvineetagoeloncologist]

Get Solitary Brain Metastases Treatment in Delhi for Liver

Dr. Vineeta Goel is best known for providing solitary brain metastases treatment in north delhi an delhi ncr; you can get in touch with her for solitary brain metastases treatment in east delhi, solitary brain metastases treatment in west delhi.

[itsmedicinesfakianakis]

Melanoma brain metastasis: the impact of stereotactic radiosurgery, BRAF mutational status, and targeted and/or immune-based therapies on treatment outcome

Journal of Neurosurgery, Ahead of Print. OBJECTIVEThe goal of this study was to investigate the impact of stereotactic radiosurgery (SRS), BRAF status, and targeted and immune-based therapies on the recurrence patterns and factors associated with overall survival (OS) among patients with melanoma brain metastasis (MBM).METHODSA total of 366 patients were treated for 1336 MBMs; a lesion-based analysis was performed on 793 SRS lesions. The BRAF status was available for 78 patients: 35 had BRAFmut and 43 had BRAF wild-type (BRAF-WT) lesions. The Kaplan-Meier method evaluated unadjusted OS; cumulative incidence analysis determined the incidences of local failure (LF), distant failure, and radiation necrosis (RN), with death as a competing risk.RESULTSThe 12-month OS was 24% (95% CI 20%–29%). On multivariate analysis, younger age, lack of extracranial metastases, better Karnofsky Performance Status score, and fewer MBMs, as well as treatment with BRAF inhibitors (BRAFi), anti–PD-1/CTLA-4 therapy, or cytokine therapy were significantly associated with OS. For patients who underwent SRS, the 12-month LF rate was lower among those with BRAFmut lesions (6%, 95% CI 2%–11%) compared with those with BRAF-WT lesions (22%, 95% CI 13%–32%; p < 0.01). The 12-month LF rates among lesions treated with BRAFi and PD-1/CTLA-4 agents were 1% (95% CI 1%–4%) and 7% (95% CI 1%–13%), respectively. On multivariate analysis, BRAF inhibition within 30 days of SRS was protective against LF (HR 0.08, 95% CI 0.01–0.55; p = 0.01). The 12-month rates of RN were low among lesions treated with BRAFi (0%, 95% CI 0%–0%), PD-1/CTLA-4 inhibitors (2%, 95% CI 1%–5%), and cytokine therapies (6%, 95% CI 1%–13%).CONCLUSIONSPrognostic schema should incorporate BRAFi or immunotherapy status and use of targeted therapies. Treatment with a BRAF inhibitor within 4 weeks of SRS improves local control without an increased risk of RN.

from #ORL-Sfakianakis via xlomafota13 on Inoreader http://ift.tt/2vrKd47

from OtoRhinoLaryngology - Alexandros G. Sfakianakis via Alexandros G.Sfakianakis on Inoreader http://ift.tt/2vXZScN

[drvineetagoeloncologist]

Dr. Vineeta Goel is best known for providing solitary brain metastases treatment in north delhi an delhi ncr; you can get in touch with her for solitary brain metastases treatment in east delhi, solitary brain metastases treatment in west delhi.

[drvineetagoeloncologist]

Dr. Vineeta Goel is best known for providing solitary brain metastases treatment in north delhi an delhi ncr; you can get in touch with her for solitary brain metastases treatment in east delhi, solitary brain metastases treatment in west delhi.

[drvineetagoeloncologist]

Dr. Vineeta Goel is best known for providing solitary brain metastases treatment in north delhi an delhi ncr; you can get in touch with her for solitary brain metastases treatment in east delhi, solitary brain metastases treatment in west delhi.

[cancersfakianakis1]

Brain metastasis growth on pre-radiosurgical magnetic resonance imaging

Publication date: Available online 7 June 2018 Source:Practical Radiation Oncology Author(s): Michael A. Garcia, Mekhail Anwar, Yao Yu, Sai Duriseti, Bryce Merritt, Jean Nakamura, Christopher Hess, Philip V. Theodosopoulos, Michael M. McDermott, Penny K. Sneed, Steve E. Braunstein BackgroundA previous analysis showed that brain metastases treated with frameless stereotactic radiosurgery (SRS) planned with MRI >14 days before SRS had worse local control (LC). To evaluate if worse LC may be due to unaccounted interval metastasis growth and radiosurgical marginal miss, we quantified growth before SRS on pre-radiosurgical imaging.MethodsWe reviewed patients treated with fixed-frame SRS for brain metastases at our institution from 2010-2013 who had pretreatment diagnostic brain MRI and SRS-planning MRI scans available. Metastases were contoured on the pretreatment MRI and the day-of-treatment planning MRI for volumetric comparison. Growth rates were calculated. Serial volumetric contour expansions on the pretreatment MRI were used to determine the minimum margin necessary to encompass the entire metastasis on day of SRS. LC was estimated by Kaplan-Meier method.ResultsAmong 411 brain metastases in 165 patients, time between pretreatment and treatment MRI was associated with metastasis growth (p<0.001) with mean growth rate of 0.02 ml/day (95% CI 0.01-0.03), and 1.35-fold volume increase at 14 days. Time between MRI scans was associated with the amount of margin needed to target the entire brain metastasis volume on day of SRS (p<0.001), as were volume of metastasis on the pretreatment MRI (p<0.001) and melanoma histology (p<0.001). LC was not associated with growth rate among fixed-frame SRS patients.ConclusionTime between pretreatment MRI and SRS is associated with brain metastasis growth, but LC is not compromised when patients receive fixed-frame SRS with same-day MRI planning. Margins may be needed for metastases treated by frameless SRS to account for growth between planning MRI and SRS delivery.In this study we quantify brain metastasis growth over time by taking advantage of the availability of two pre-treatment MRI scans taken at two time points among patients treated with frame-fixed radiosurgery. We found metastasis growth is associated with time, initial metastasis size, melanoma histology, and concurrent chemotherapy. Performing serial margin expansions demonstrated factors that are associated with the amount of margin needed to target the entire metastasis on day of radiosurgery. https://ift.tt/2HqRG6j

[ourhaileydavies]

Biopsy-Proven Brain Metastases from Prostate Adenocarcinoma on 68Ga PSMA PET/CT: Case Series and Review of the Literature-Juniper publishers

Abstract

Prostate cancer brain metastases are extremely rare and typically occur at a late stage in the course of the disease with poor prognosis. However, the incidence is rising as novel antiandrogens and radionuclide therapy prolong survival and change the natural course of the disease. Surveillance imaging of the brain is not the current standard of care. We present two cases of patients who had brain metastases from prostate adenocarcinoma initially detected on prostate specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and also provide a review of the epidemiology, pathogenesis, imaging features, pathogenesis and current treatment modalities of prostate cancer brain metastases. Our patient with multiple brain metastases is still alive three and a half years post initial diagnosis after being successfully treated with surgery, androgen deprivation therapy and radiosurgery. This is the longest survival time of any patient with multiple brain metastases and systemic disease. We postulate that overall survival will increase with earlier detection and treatment of brain metastases from a prostate cancer primary and that scanning vertex to mid-thigh should be standard practice with PSMA PET imaging.

Keywords: Brain metastasis; Prostate cancer; Neuroradiology; Ga68PSMA PET/CT

Abbrevations: PCa: Prostate Cancer; Ga: Gallium; PSMA: Prostate Specific Membrane Antigen; PET/CT: Positron Emission Tomography/Computed Tomography; MRI: Magnetic Resonance Imaging; SRS: Stereotactic Radiosurgery; Gy: Gray; PSA: Prostate Specific Antigen; PAP: Prostatic Acid Phosphatase; ADT: Androgen Deprivation Therapy

Case 1

A neurologically intact 66-year-old man presented for a Ga68 prostate specific membrane antigen (PSMA) positron emission tomography (PET) scan due to a rising prostate specific antigen (PSA) level of 7.4ng/ml thirteen years after a successful radical prostatectomy for a Gleason 7 prostate cancer (PCa).

PSMA demonstrated an unusual distribution of disease with intensely PSMA avid foci in an enlarged mediastinal lymph node, within small lung nodules and in two PSMA avid brain foci within the right temporal and left occipital lobes. Brain MRI revealed a large 6.5cm complex enhancing lesion in the right temporal lobe compressing the temporal horn and the body of the right lateral ventricle. The cystic component of the mass showed no restricted diffusion. A second 1.1cm lesion was noted in the left occipital lobe superior to the ventricular trigone with peripherally restricted diffusion and increased diffusibility centrally (Figure 1).

The patient underwent a right temporal craniotomy and excision with gross total resection achieved (Figure 2). Histology confirmed metastatic prostatic adenocarcinoma with positive immunohistochemistry for PAP and PSA. The patient received adjuvant stereotactic radiosurgery (SRS) to the right temporal lobe cavity, left parietal lobe mass and hormonal manipulation with androgen deprivation therapy (ADT).

Nine months postoperatively, the patient remained clinically well with no neurological symptomology and undetectable PSA with ongoing ADT. MRI brain confirmed no recurrence in the right temporal lobe cavity but an increase in the size of the left occipital lobe lesion. PSMA PET/CT demonstrated mild persistent increased PSMA avidity in a solitary focus in the left occipital lobe. Complete metabolic response at all other metastatic sites with no new disease found. The patient was treated with further SRS (14Gy in a single fraction) to the region of PSMA avidity in the left occipital lobe. Three and a half years post operatively, he remains well with good disease control.

Case 2

A 71-year-old man with metastatic castration resistant prostate cancer previously treated with external beam radiotherapy, ADT, radium 223 therapy and docetaxel presented with a three-week history of increasing confusion and ataxia.

MRI brain revealed a well circumscribed 2.4 x 2.0cm cystic, enhancing mass in the left para-median thalamus and midbrain compressing the cerebral aqueduct and five other lesions throughout the bilateral cerebellar hemispheres. The thalamic cyst was biopsied and aspirated, but his symptoms persisted. Histologic examination confirmed metastatic prostatic adenocarcinoma. He was treated with whole-brain radiotherapy but passed away two months following radiation treatment.

Introduction

Intraparenchymal metastases from a prostate adenocarcinoma primary is rare and only occur in an estimated 0.6-1.9% of patients [1-3]. However, the incidence is increasing as novel antiandrogens and radionuclide therapy prolong survival and change the natural course of the disease.

On the 1st of May 2018, a comprehensive literature search examining peer-reviewed, English language articles from 1982 to 2018 was performed on multiple databases, yielding 1286 articles. These articles were reviewed and selected for studies that met the following inclusion criteria;

a) Patients with intraparenchymal metastases from prostate adenocarcinoma proven either on antemortem resection or stereotactic biopsy and

b) Metastases confirmed on CT or MR brain imaging.

Additional relevant studies were also searched manually in the reference lists of identified studies and by using the “related articles” tool in PubMed. Patients with dural or skull-based tumours extending into the brain were excluded from the review. We found 1286 articles and considered 29 articles eligible. A total of 47 men with brain metastases from prostate adenocarcinoma origin confirmed on radiological imaging and antemortem biopsy was thus identified in the literature (including our 2 cases reported here).

Discussion

Epidemiology

For patients with brain parenchymal metastases from prostate adenocarcinoma of any subtype, the mean at diagnosis of brain metastasis was 66.3 years (range, 48-88 years) and the median age was 66 years.

35 of the 47 men had known prostate adenocarcinoma at the time of their cerebral metastasis diagnosis whilst for 12 men this was the initial presentation of their primary prostate tumour. The mean age at diagnosis of brain metastasis for men with known prostate cancer (PCa) was 65.5 years (range, 48- 88 years). In patients with cerebral metastases as the initial presentation of their primary tumour, the mean age of brain metastasis diagnosis was 66.4 years (range, 56-75 years).

Hatzoglou et al. [4] study of 7 patients with biopsy proven brain metastasis from prostate adenocarcinoma was not included as we were unable to differentiate the patients’ mean age at diagnosis of brain metastasis from other patients in their cohort who had biopsy from other sites of distant disease confirming metastatic PCa.

Timing and symptoms

Patients with metastatic disease to the brain developed disease an average of 4.4 years (range, 3 days to 13 years) after the initial diagnosis of their PCa. New therapies increasing overall survival time gives the tumour enough time to develop brain metastases, that is usually a late event of the disease [5,6].

Neurological manifestations on presentation varied according to the anatomical site with most metastases situated in arterial border zones and the junction between the cortex and subcortical white matter. The majority of patients (95.7%) presented with overlapping neurological signs and symptoms. 22 patients presented with headache, the most common presenting complaint at diagnosis followed by motor weakness (n=16), ataxia (n=13), confusion (n=10), seizures (n=8), speech impairment (n=7) and visual field disturbances(n=4). In the two neurologically asymptomatic patients, the brain metastases were diagnosed on surveillance imaging after a rise in PSA.

In 11 patients, the brain was the sole site of distant metastasis [7-16]. In patients with metastatic disease, the most common extra prostatic sites were bone (61.7%), lungs (26.4%), liver (16.1%) and lymph nodes (13%).

Lesion characteristics

A total of 73 metastases was seen in the 47 patients. 39 patients (83%) had a solitary brain metastasis whereas the other 8 patients (17%) had multiple metastases. Four patients (8.5%) had two metastases and 4 patients (8.5%) had 6 or more brain metastases.

The frontal lobe (n=15) and the cerebellum (n=15) were the most prevalent sites of metastases followed by the parietal (n=14), temporal (n=12) and occipital (n=6) lobes. One patient had a solitary metastasis in the temporo-parietal lobe and one case involved the parieto-occipital lobe. Five patients had 6 metastases in the brainstem. Two cases involved the cavernous sinus and one patient (our case) had a metastasis in the thalamus. 49 patients (67.1%) had parenchymal metastases located in the cerebral hemispheres which corresponds to what is known about the distribution of parenchymal metastases from other primary cancers.

15 patients (20.5%) with brain metastases from PCa origin were found in the cerebellum and only 8.2% of metastases were found in the brainstem. This distribution of intracranial metastases is similar to metastases from breast, lung and melanoma where approximately 15% of metastases are found in the cerebellum. Brainstem are uncommon sites especially for solitary lesions and account for <1% of all brain metastases. Interestingly 3 patients (4.1%) in our review of all the literature to date had solitary metastases in the brainstem [8-9,17].

31 patients (68.9%) had one or more metastatic brain lesions in the supratentorial compartment [7,9-13,16,18-25], 11 patients (24.4%) in the infratentorial compartment [8- 10,13-14,17,23,26] and 3 patients (6.7%) in both compartments [27-29]. Two patients with lesions in the cavernous sinus were excluded.

Intraparenchymal cerebral metastases from prostate adenocarcinoma are rare and multiple metastases without systemic disease is exceedingly uncommon. In the largest case series to date of 16280 patients with brain metastases from prostate cancer by Tremont-Lukats et al. [1] only 103 patients (0.6%) had parenchymal brain metastases. In most cases the metastases were singular (86%) and supratentorial (76%). Only 3 patients (2.9%) of the cohort had both infratentorial and supratentorial metastases.

A more recent case series by Hatzoglou et al. [4] found 10 patients (47.6%) of their cohort had both supratentorial and infratentorial metastases. This is significantly higher than other case series to date and is likely due to MRI images from Hatzoglou’s case series being reviewed by a neuroradiologist versus some cases in our review being limited to only single slice images of patients’ CT or MRI which limits our ability to ascertain the distribution of lesions outside of our two cases.

Gross pathology

Parenchymal metastases are generally round, discrete lesions. The metastases in our review had variable peritumoural oedema, necrosis and mass. Non-uniformity in the spatial distribution of the parenchymal metastases suggests that vulnerability to metastases differ according to its anatomical location. Our review found parenchymal metastases from PCa had a predilection for the frontal lobe and cerebellum (n=15, 20.5%) which is consistent with other large case series which found 17-25% of metastases from PCa were found in the cerebellum [1,4]. Unlike melanoma, renal cell carcinoma and choriocarcinoma which are particularly prone to developing intratumoural haemorrhages, brain metastases from PCa was not found to have intratumoural haemorrhage on imaging or histopathology. All of the patients included in our review had biopsy confirmed adenocarcinoma with positive immunohistochemical staining for PSA and PAP.

Imaging features

The cerebral metastases had highly variable imaging appearance and was difficult to differentiate from metastases originating from other primary tumour sites. Eight patients in our review only had CT imaging of their cerebral metastases [7,9,18-21,26]. On non-contrast CT imaging, most metastases were isodense to slightly hypodense relative to grey matter. The majority of parenchymal metastases enhanced strongly following contrast administration.

On axial T1-weighted MRI, most of the parenchymal lesions were mildly hypointense. On post gadolinium imaging, nearly all of the non-haemorrhagic metastases showed enhancement with patterns of disease varying from solid uniform enhancement to nodular or ring like lesions. FLAIR imaging also demonstrated significant variability in lesion cellularity, presence of haemorrhage and amount of peritumoural oedema. On diffusion weighted imaging (DWI), well differentiated adenocarcinoma metastases generally showed no diffusion restriction compared to highly cellular metastases which demonstrated diffusion restriction.

Cystic intraparenchymal metastases from PCa are rare with only eight cases documented in literature to date, including our two patients [11,19,22-23,27,30]. Five patients had solitary cystic lesions and three patients had multiple cystic lesions. Intralesional restricted diffusion was present in both our patients.

Unlike true intraparenchymal cerebral metastases of prostate adenocarcinoma origin, prostate cancer is the second most common primary after breast cancer to metastasize to the dura [5] and poses a radiological diagnostic challenge especially when it presents as a solitary lesion which can be mistaken for a meningioma as up to 44% of prostate metastases have a dural tail [6,31,32]. Distinguishing between the two lesions is important due to the poor prognosis of intracranial metastatic PCa and the potential for conservative management versus active treatment if a radiological diagnosis is made. The incidence of brain metastases in the most recent series of 16,280 prostate cancer patients is reported to be around 0.63% [1] which is less than the 1-2.4% incidence reported in autoptic series [3,33-34] with the incidence of brain metastases being detected in the pre-MRI era the same as in the post MRI era [1]. We postulate that advances in MR imaging such as triple dose gadolinium and or 3.0Tesla (T) MRIs have led to earlier detection of metastases in PCa patients which allow earlier treatment and thus decrease the potential for further extraprostatic spread.

Ga68 PSMA PET/CT imaging appears to have superseded F18 FDG PET/CT, CT and MR imaging not only in the staging of PCa but also in the detection of PSMA-avid disease and is increasingly being used for restaging recurrent PCa. Our case demonstrates the importance of scanning from vertex to mid-thigh as albeit rare, PCa can metastasize to the brain and earlier detection and treatment correlates directly with improved survival time and quality of life.

Treatment

All of the patients included in our review underwent either surgical resection (n=37) or stereotactic biopsy (n=9) of their intracranial lesion which confirmed their diagnosis on histopathology. 31 patients (66%) underwent whole-brain irradiation; 22 patients had adjuvant whole-brain radiotherapy post-surgical resection of their lesion and 9 patients had whole-brain radiotherapy as their primary treatment. Three patients had stereotactic radiosurgery (SRS) to their lesion; 1 in conjunction with whole-brain radiotherapy post-surgical resection and 2 patients had SRS post-surgical resection of the main symptomatic lesion. 6 patients had trimodality treatment with surgical resection, whole-brain radiotherapy and ADT [10,13,18-19,24-26]. One patient had surgical resection of the dominant metastasis, SRS to another metastasis and also received concurrent androgen deprivation therapy (our case).

Surgical resection with adjuvant whole-brain radiotherapy has been the Gold standard for treating solitary metastasis in the brain. This combined strategy has been evaluated in randomised controlled trials to significantly prolong survival, alleviate neurological symptoms and reduce the risk of recurrence when compared with surgical resection or whole-brain radiotherapy alone [35].

ADT have also been found to bring both symptomatic and radiological improvement [36-37] leading not only to an increase in the overall survival time but also an improved quality of life and is thus used in both the curative and palliative settings in patients with prostate adenocarcinoma.

Prognosis

For the 41 patients who had documented survival times from the initial detection of their brain metastases, the mean survival time was 13.7 months (range, 3 days to 7 years). The patient who had the longest survival time of 7 years in our series had a solitary metastasis in the cerebellum that was resected en bloc and also underwent a bilateral orchiectomy. Previous case series have reported a median duration from diagnosis to death of between 3.5 to 31 months [1,38-39]. Patients without systemic disease were less likely to have brain lesions [4]. Patients with brain metastasis as the sole site of extra-prostatic disease had a mean overall survival time of 24.6 months (range, 1month to 7 years) compared to 13.4 months (range, 3 days to 5 years) in patients with systemic disease.

We postulate that advances in imaging such as Ga68 PSMA PET/CT, triple dose gadolinium and 3.0 Tesla (T) MRIs have led to earlier detection of metastases in PCa patients which allow the patient to be treated earlier thus decreasing the potential for further extraprostatic spread and the increased incidence of patients presenting with brain metastases as the sole site of disease from their primary PCa.

Solitary brain metastasis has better prognosis than patients with multiple brain metastases. The overall survival time for patients with a solitary brain metastasis was 14.3 compared to 7.2 months (range, 3 days to 29 months) for patients with multiple metastases. Our patient had the longest survival time for a patient with multiple brain metastases of three years likely due to low volume disease in the brain post-surgical resection and exceptional response to ADT at the extracranial metastatic sites.

The mean overall survival time for patients who had surgical resection was 20.3months (range, 3 weeks to 7 years). The mean overall survival time for patients who had stereotactic biopsies was considerably shorter at 6.25 months (range, 1month to 2years). This latter cohort of patients either had disease in the brainstem that was unresectable [8,17,21] or had multiple cerebral metastases [13,16,28].

Prior to the introduction of docetaxel in 2002, the incidence of prostatic brain metastasis from 1994 to 2002 was 0.8%. In the post-docetaxel era (2002-2011), this incidence had increased to 2.8%. This represents a 239% increase in the frequency of brain metastases from PCa between the two observation periods [40]. As the appearance of parenchymal metastases usually occurs in the late phase of the disease process it appears that the increase in frequency may actually reflect a gain in overall survival. In general patients are living longer with brain metastases in the context of PCa due to advances in imaging ability, systemic treatment and increased surveillance.

Pathogenesis

PCa rarely metastasizes to the brain with the incidence in large case series ranging from 0.63 to 1.1% [2,41] which suggests that the brain parenchyma is resistant to the establishment of metastatic foci by prostate carcinoma cells.

Currently the pathogenesis of cerebral metastases from PCa is unknown however in summary there are two main mechanisms postulated;

a) Single step spread via Batson’s paravertebral venous plexus draining the prostate. Low pressure in the large venous plexus allowing Valsalva maneuver to generate enough pressure to reverse blood flow from the IVC to the venous plexus, avoiding the lung and reaching the CNS. This mechanism however does not explain the absence of vertebral metastases and

b) Multi step haematogenous spread where secondary seeding of tumour cells to the brain occur from a primary metastatic focus involving the lungs or bones with brain metastasis usually a late event in the course of prostate cancer.

Haematogenous metastases have a special predilection for arterial border zones and the junction between the cortex and subcortical white matter. PSA is a sensitive indicator of the presence of disease however serum levels of PSA did not correlate to the development of brain metastases in our cases which is consistent with what is found in other case series [11,22].

Conclusion

Intraparenchymal spread of prostate cancer should be considered in men over the age of 60 years as a treatable cause of gradual neurological deterioration especially if a cranial malignancy or hyperostosis is found. The incidence of intraparenchymal brain metastasis is only expected to increase due to the longer life expectancy of patients with prostate adenocarcinoma with novel therapies. Patients undergoing Ga68-PSMA PET/CT for staging of PCa or when there is a PSA rise should be scanned from vertex to mid-thigh as albeit rare, prostate cancer brain metastases is a not to be missed differential in this particular group of patients.

Consent

The patients provided informed consent to the publication of their data, de-identified PET and MRI scans. No ethics approval through an institutional committee on human research was required.

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[cancersfakianakis1]

Control of intracranial disease is associated with improved survival in patients with brain metastasis from hepatocellular carcinoma

Abstract

Background

Brain metastasis is a rare event in patients with hepatocellular carcinoma (HCC). This retrospective study aimed to identify the prognostic factors and determine the outcomes of patients with brain metastases from HCC.

Methods

About 86 patients with brain metastases (0.6%) from HCC were identified from two institutions; of them, 32 underwent tumor-removing surgery or stereotactic radiosurgery (SRS) with or without adjuvant whole brain radiotherapy (WBRT) (group 1), 30 had WBRT alone (group 2), and 24 received conservative treatment (group 3). Estimates for overall survival (OS) after brain metastases were determined, and clinical prognostic factors were identified.

Results

The median OS after development of brain metastases was 50 days. About 75 (87.2%) patients had lung metastases at the time of brain metastasis diagnosis. Group 1 showed better OS, followed by group 2 and group 3, sequentially (p < 0.001). Univariate analyses showed that treatment with curative intent (surgery or SRS), Child–Pugh class A, alpha-fetoprotein level < 400 ng/ml, and recursive partitioning analysis classification I or II were associated with improved survival (p < 0.001, 0.002, 0.029, and 0.012, respectively). Multivariate analysis showed that treatment with curative intent and Child–Pugh class A was associated with improved OS (p < 0.001 and 0.009, respectively).

Conclusion

Although the overall prognosis of patients with brain metastases from HCC is extremely poor, patients actively treated with surgery or radiosurgery have prolonged survival, suggesting that interventions to control intracranial disease are important in these patients.

https://ift.tt/2GBbl7j

[cancersfakianakis1]

Laser-interstitial thermal therapy compared to craniotomy for treatment of radiation necrosis or recurrent tumor in brain metastases failing radiosurgery

Abstract

Purpose

Many publications report laser-interstitial thermal therapy (LITT) as a viable alternative treatment to craniotomy for radiation necrosis (RN) and re-growing tumor occurring after stereotactic radiosurgery (SRS) for brain metastases. No studies to-date have compared the two options. The aim of this study was to retrospectively compare outcomes after LITT versus craniotomy for regrowing lesions in patients previously treated with SRS for brain metastases.

Methods

Data were collected from a single-institution chart review of patients treated with LITT or craniotomy for previously irradiated brain metastasis.

Results

Of 75 patients, 42 had recurrent tumor (56%) and 33 (44%) had RN. Of patients with tumor, 26 underwent craniotomy and 16 LITT. For RN, 15 had craniotomy and 18 LITT. There was no significant difference between LITT and craniotomy in ability to taper off steroids or neurological outcomes. Progression-free survival (PFS) and overall survival (OS) were similar for LITT versus craniotomy, respectively: %PFS-survival at 1-year = 72.2% versus 61.1%, %PFS-survival at 2-years = 60.0% versus 61.1%, p = 0.72; %OS-survival at 1-year = 69.0% versus 69.3%, %OS-survival at 2-years = 56.6% versus 49.5%, p = 0.90. Craniotomy resulted in higher rates of pre-operative deficit improvement than LITT (p < 0.01). On subgroup analysis, the single factor most significantly associated with OS and PFS was pathology of the lesion. About 40% of tumor lesions needed post-operative salvage with radiation after both craniotomy and LITT.

Conclusions

LITT was as efficacious as craniotomy in achieving local control of recurrent irradiated brain metastases and facilitating steroid taper, regardless of pathology. Craniotomy appears to be more advantageous for providing symptom relief in those with pre-operative symptoms.

http://bit.ly/2Hk9Z26