Stereotactic Radiotherapy for the Treatment of Recurrent Refractory Vt in Chagas Disease Patients

Background: Stereotactic radiotherapy (SBRT) is a new therapeutic option for patients with scar related ventricular tachycardia (VT). Objective(s): To describe our experience with the use of SBRT for the treatment of recurrent VT in patients with Chagas Cardiomyopathy (CCM) in whom catheter ablation is not an option. Method(s): We selected patients with Chagas Disease that underwent SBRT for recurrent VT treatment. The target sites of SBRT were planned based on CMR and CT reconstruction on ADAS software, bipolar voltage maps from previous CA procedures and VT morphology induced on a electrophysiologic study performed SBRT planning. Target sites were decided together by electrophysiology and radiation oncology group. Result(s): We performed SBRT in six CCM patients July 2021 to July 2022. Most patients were male (66.7%), mean age 62.3+/-5.7 years-old and EF 28.5% (Q1: 20 Q3:42.7). One patient (16.7%) had two prior catheter ablation, four (66.7%) had one and one patient had no prior ablation, but had severe pulmonary fibrosis after COVID and was O2 dependent. The mean PTV (planning target volume) was 85+/-14 mL and the ITV (internal target volume) was 29+/-4 ml, with safe constraints regarding the esophagus and stomach. In a mean FU of 244+/-173days, 3 (50%) patients presented VT recurrence after blanking period. Two patients died 86 and 50 days after SBRT. The median number of VT episodes reduced from 13 (6.25;44.75) to 7.5 (3;7.5) (P = 0.093). All alive patients stop presenting VT in a median period of 174 (Q1: 44.75: Q3: 199) days, being at the end of the follow-up in a median of 196 (Q1: 137;Q3: 246) days without new VT episodes. Conclusion(s): SBRT presents a high rate of early recurrence in Chagas disease patients that improves during timeCopyright © 2023

Eastern Regional Meeting 2021

The proceedings contain 63 papers. The topics discussed include: doxorubicin cardiotoxicity in human organotypic cardiac slices is modulated by P38 MAPK inhibition in a sex- and isoform-specific manner;validation of a modified response evaluation criteria in solid tumors after stereotactic ablative radiosurgery for lung cancer;safer use of aspirin in older adults, need for a consensus;efficacy of facemasks in prevention of COVID-19: a systematic review;practice patterns of rapid influenza diagnostic test;equity and inclusion in patient centered outcomes research: lessons from the adaptable study at Montefiore site;a solution to decrease potentially inappropriate medications (PIM) use during hospitalization;predictors of misperceptions, risk perceptions, and personal risk perceptions about COVID-19 by country, education and income;cognitive function and the consumption of probiotic foods in older adults: an NHANES study;and registered dietitian nutritionist care impacts nutrition-related outcomes for patients with cancer in the outpatient setting.

Possible consequences of Covid-19 on the nervous system

OBJECTIVES: The aim of the survey was to find out what the possible consequences are of the COVID-19 disease on the nervous system and to propose a method of using artificial intelligence. MATERIAL AND METHODS: Recent research has shown that the risks to patients due to severe acute coronavirus 2 respiratory syndrome (SARS-COV-2) differ most significantly depending on age and the presence of underlying comorbidities such as: cardiovascular disease, hypertension, diabetes and others. The consequences of COVID-19 on the nervous system are especially important. We performed a detailed selection of articles describing the effects of COVID-19 on the nervous system. RESULT(S): We made a clear summary of the main consequences of COVID-19 on the nervous system and suggested a way to use artificial intelligence. CONCLUSION(S): We confirmed research that artificial intelligence methods have the potential to accelerate prediction, especially for the possible consequences of COVID-19 on the nervous system.Copyright © 2020 Neuroendocrinology Letters

BRIDGING THE COMMUNICATION GAPS WITH HEARING IMPAIRED/NEWLY DIAGNOSED VESTIBULAR SCHWANNOMA PATIENTS DURING GAMMA KNIFE RADIOSURGERY

At the Center for Advanced Radiosurgery, patients with Acoustic Schwannomas are treated with Gamma Knife Radiosurgery. Between 2019 and 2020, 161 patients with acoustic schwannomas received Gamma Knife Radiosurgery. Often times these patients are diagnosed later in life and therefore struggle with communication because they lack alternative language skills such as sign language or lip reading. This was also compounded by the COVID-19 pandemic, adding a barrier posed by mask wearing. This lead to miscommunication, frustration on the part of both patient and staff. In order to mitigate this we created a "Gamma Knife Hearing Impaired" tool. Newly diagnosed patients with schwannomas are not equipped with the skills normally used by those who are diagnosed at birth or earlier in life. Communication can become very daunting, with both staff members and patients wearing masks throughout the pandemic, communication became even more difficult. In order to give clear, concise instruction and patient education, the nurses created a Gamma Knife Hearing Impaired tool. The Gamma Knife Radiosurgery Hearing Impaired Script was created. A power point which mimics the workflow of a patient receiving Gamma Knife Radiosurgery was created. It was divided into separate packets to coincide with the various portions of the Gamma Knife procedure. Each section includes a blank page for free writing and a page which contains a pain score. Utilizing our post procedure survey our patients found that the tool made their experience less confusing and decreased the delay in communication. We found that 100% of our patients found the tool to be helpful and easy to use. Effective communication between nurses and patients is a vital part of safe and effective nursing care. However, few health care professionals receive training on how to communicate with people who are hearing impaired. Our patients who we were able to utilize this tool, found it to be 100% helpful during their treatment. The Gamma knife Hearing Impaired Tool, allowed us to communicate more effectively and efficiently with our patients who have such communication barriers, thereby leading to increased patient satisfaction.

Accommodating ''History Effects'' in Long Duration, Multisite Clinical Trials to Ensure Relevant and Compelling Evidence

Over the course of a clinical trial, changes in the practice environment have the potential to reduce internal and external validity and impact change in patient outcomes. Such ''history effects''1 can take the form of changes in standard of care, clinical guidelines and recommendations, new drug/device availability in the marketplace, testing and screening procedures, and, as recently experienced, a global pandemic. Clinical trials conducted over many years are particularly susceptible to history effects. Such effects can impact foundational ability to continue a trial, including clinician equipoise and ability to implement trial interventions, necessitating awareness and action planning. For example, Curtis et al.2 acknowledged challenges with clinical guideline history effects and issued recommendations for addressing them such as consideration of participant wellbeing, stakeholder engagement, safety monitoring, review of guideline and policy changes, and development of rules for protocol changes. This session will explore how four multisite clinical trials conducted with VA Cooperative Studies Program sponsorship and coordination have weathered history effects during prolonged periods of enrollment. Topics to be covered include the implementation of pragmatic designs, monitoring of clinical guidelines, assessing control group treatment conditions, modifying protocols, adjusting quality assurance procedures, refining recruitment pathways, and training site investigators. The speakers, Study Chairs, will describe best practices and provide recommendations for navigating history effects in prolonged multisite clinical trials that can ensure outcomes remain relevant and compelling to inform public health at trial commencement. The CSP 2008/PTXRx study is a pragmatic, randomized, double-blind, placebo-controlled, multicenter clinical trial of Veteran patients with diabetic kidney disease (DKD) examining whether pentoxifylline (PTX), when added to usual care, can delay time to end-stage renal disease or death. Enrollment for the study began in 2019, and it is anticipated that 9 years of follow-up will be required to observe the required number of primary events. Given the long duration of the study, changes in clinical guidelines were anticipated and have occurred, including the approval of new DKD therapies and introduction of a new formula for estimated glomerular filtration rate (eGFR) calculation. In anticipation of these changes, the study design allows for whatever standard of care is extant at any time during the course of the study. PTXR's pragmatic trial design and protocol leverage the VA's research infrastructure and remote platforms allowing the study to be responsive to external changes and to safely continue during a global pandemic. The CSP 596/OPTION study is a randomized, double- blind, multicenter trial of Veteran patients with a first or second recurrent Clostridium difficile infection (CDI) comparing (1) fidaxomicin and (2) vancomycin, followed by a taper and pulse to (3) a standard vancomycin regimen. Since enrollment began in 2016, significant changes in CDI epidemiology and clinical management have impacted the study. The COVID-19 pandemic also resulted in an administrative hold on all trial activity followed by staggered reopening of sites due to variable COVID-19 activity and clinical priorities. Many clinical laboratories switched to algorithms that included free toxin assays in addition to polymerase chain reaction (PCR) tests out of concern for overdiagnosis based on PCR testing alone, reducing the number of potentially enrollable cases. There has been increased empirical vancomycin treatment for recurrent CDI without confirmation by stool testing, a requirement for enrollment, and a recruitment strategy for identifying potential cases. Finally, conflicting clinical guidelines for recurrent CDI has created potential equipoise when considering enrollment. Ongoing educational efforts have been made to clarify the protocol and emphasize the validity of the research question as well as protoco changes to allow safe enrollment and follow-up of participants in the face of the ongoing COVID-19 pandemic. The CSP 2005/VALOR is a phase III randomized, open label, multicenter clinical trial of Veteran patients with operable stage I non-small cell lung cancer that compares stereotactic radiotherapy and anatomic pulmonary resection with a primary outcome measure of overall survival. The study was activated in 2017 and recruitment to the trial has been affected by ongoing changes in public and clinician perceptions about stereotactic radiotherapy and surgery that have interfered with equipoise and willingness of participants to enroll. The study team perpetually addresses this challenge through group conversations with local site investigators, study coordinators, and other research personnel to preserve group equipoise across the study. Since the study's activation, new safety information about stereotactic radiotherapy has emerged necessitating protocol modifications while aiming to preserve internal and external validity. The includes modifying standard operating procedures for the study's centralized quality assurance program that has had to adapt its process to remain contemporary. STARPORT, funded by VA CSRD with CSP collaboration, is a randomized, open label, multicenter clinical trial of Veteran patients with oligorecurrent prostate cancer comparing the effects of standard systemic therapy (SST) alone or with PET-directed local therapy using surgery or radiation. Although enrollment was initiated in 2021, changes are already evident in clinical practice guidelines regarding the use of imaging in workup in this patient population. Shortly before the start of accrual, 18F-DCFPyL PSMA PET/CT received FDA-approval. Consequently, it is being rapidly adopted at the STARPORT VA medical centers and the use of conventional imaging using CT or bone scan prior to PET/CT imaging-part of the original eligibility criteria-quickly is falling out of favor. Furthermore, shortly after the start of enrollment, NCCN guidelines adopted the stance that conventional imaging was no longer required in the setting of PSMA PET/CT imaging, solidifying the transition away from conventional imaging. Thus, the protocol is being amended to remove the requirement for conventional imaging as part of workup for oligorecurrence. In addition, to be generalizable, the study is designed to integrate future PSMA radiotracers that are incorporated into practice as well as changes in SST regimens over the time of the study.

The Effectiveness and Toxicity of Frameless CyberKnife Based Radiosurgery for Parkinson's Disease-Phase II Study.

Frame-based stereotactic radiosurgery (SRS) has an established role in the treatment of tremor in patients with Parkinson's disease (PD). The low numbers of studies of frameless approaches led to our prospective phase 2 open-label single-arm clinical trial (NCT02406105), which aimed to evaluate the safety and efficacy of CyberKnife frameless SRS. Twenty-three PD patients were irradiated on the area of the thalamic ventral nuclei complex with gradually increasing doses of 70 to 105 Gy delivered in a single fraction. After SRS, patients were monitored for tremor severity and the toxicity of the treatment. Both subjective improvement and dose-dependent efficacy were analysed using standard statistical tests. The median follow-up was 23 months, and one patient died after COVID-19 infection. Another two patients were lost from follow-up. Hyper-response resulting in vascular toxicity and neurologic complications was observed in two patients irradiated with doses of 95 and 100 Gy, respectively. A reduction in tremor severity was observed in fifteen patients, and six experienced stagnation. A constant response during the whole follow-up was observed in 67% patients. A longer median response time was achieved in patients irradiated with doses equal to or less than 85 Gy. Only two patients declared no improvement after SRS. The efficacy of frameless SRS is high and could improve tremor control in a majority of patients. The complication rate is low, especially when doses below 90 Gy are applied. Frameless SRS could be offered as an alternative for patients ineligible for deep brain stimulation; however, studies regarding optimal dose are required.

Telemedicine for Cranial Radiosurgery Patients in a Rural U.S. Population: Patterns and Predictors of Patient Utilization.

Introduction: Telemedicine retains potential for increasing access to specialty providers in underserved and rural communities. COVID-19 accelerated adoption of telehealth beyond rural populations, serving as a primary modality of patient-provider encounters for many nonemergent diagnoses. Methods: From 2020 to 2021, telemedicine was incorporated in management of stereotactic radiosurgery patients. Retrospective data on diagnoses, demographics, distance to primary clinic, and encounter type were captured and statistically analyzed using descriptive measures and Cox proportional regression modeling. Graphical representation of service areas was created using geo-mapping software. Results: Patients (n = 208) completed 331 telemedicine encounters over 12 months. Metastases and meningiomas comprised 60% of diagnoses. Median age was 62 years with median household income and residential population of $44,752 and 7,634 people. The one-way mean and median travel distances were 74.6 and 66.3 miles. The total potential road mileage for all patients was 44,596 miles. A total of 118 (57%) patients completed video visits during the first encounter, whereas 90 (43%) opted for telephone encounters. At 12 months, 138 patients (66%) utilized video visits and 70 (34%) used telephone visits. Predictors of video visit use were video-enabled visit during the first encounter (hazard ratio [HR] 2.806, p < 0.001), total potential distance traveled (HR 1.681, p < 0.05), and the need for more than one visit per year (HR 2.903, p < 0.001). Discussion: Telemedicine can be effective in radiosurgery practice with predictors of video-enabled use being pre-existing patient comfort levels with videoconferencing, total annual travel distance, and number of visits per year. Age, rural population status, and household income did not impact telemedicine use in our patient cohort.

Is single fraction the future of stereotactic body radiation therapy (SBRT)? A critical appraisal of the current literature.

Stereotactic Body Radiation Therapy (SBRT) is a standard of care for many localizations but the question of the optimal fractionation remains a matter of concern. If single fraction sessions are routinely used for intracranial targets, their utilization for mobile extracranial lesions is a source of debate and apprehension. Single session treatments improve patient comfort, provide a medico-economic benefit, and have proven useful in the context of the SARS-CoV 2 pandemic. However, both technical and radiobiological uncertainties remain. Experience from intracranial radiosurgery has shown that the size of the target, its proximity to organs at risk, tumor histology, and the volume of normal tissue irradiated are all determining factors in the choice of fractionation. The literature on the use of single fraction for extracranial sites is still scarce. Only primary and secondary pulmonary tumors have been evaluated in prospective randomized trials, allowing the integration of these fractionation schemes in daily practice, for highly selected cases and in trained teams. The level of evidence for the other organs is mainly based on dose escalation or retrospective trials and calls for caution, with further studies being needed before routine use in clinical practice.

Neurosurgery in India: Perspective of a Veteran Neurosurgeon

NFL-derived markers correlate with magnetic resonance imaging (MRI)-derived markers and predicts white matter degeneration and functional outcome at 6 to 12 months. Usual diagnostic methods for neurocysticercosis include computed tomography, MRI, and blood/serum based immunological tests. Neurosurgery is rapidly evolving specialty and neurosurgeons are passionate professionals in learning the complex procedures. [Extracted from the article]

Influence of COVID-19 pandemic on the decision making of patients in undergoing gamma knife radiosurgery.

PURPOSE: Gamma knife radiosurgery (GK) is a commonly used approach for the treatment of intracranial lesions. Its radiation response is typically not immediate, but delayed. In this study, we analyzed cases from a prospectively collected database to assess the influence of COVID-19 pandemic on the decision making in patients treated by gamma knife radiosurgery. METHODS: From January 2019 to August 2021, 540 cases of intracranial lesions were treated by GK with 207 cases before COVID-19 pandemic as a control. During the COVID-19 pandemic, 333 cases were similarly treated on patients with or without the COVID-19 vaccination. All the GK treated parameters as well as time profile in the decision making were analyzed. The parameters included age, sex, characteristic of lesion, targeted volume, peripheral radiation dose, neurological status, Karnofsky Performance Status (KPS), time interval from MRI diagnosis to consultation, time interval from the approval to treatment, frequency of outpatient department (OPD) visit, and frequency of imaging follow-up. RESULTS: Longer time intervals from diagnosis to GK consultation and treatment were found in the pandemic group (36.8 ± 25.5/54.5 ± 27.6 days) compared with the pre-COVID control (17.1 ± 22.4/45.0 ± 28.0 days) or vaccination group (12.2 ± 7.1/29.6 ± 10.9 days) (p < 0.001, and p < 0.001, respectively). The fewer OPD visits and MRI examinations also showed the same trends. High proportion of neurological deficits were found in the pandemic group (65.4%) compared with the control (45.4%) or vaccination group (58.1%) (p < 0.001). The Charlson comorbidity in the pandemic group was 3.9 ± 3.3, the control group was 4.6 ± 3.2, and the vaccination group was 3.1 ± 3.1. There were similar inter-group difference (p < 0.001). In multiple variant analyses, longer time intervals from the diagnosis to consultation or treatment, OPD frequency and MRI examination were likely influenced by the status of the COVID-19 pandemic as they were alleviated by the vaccination. CONCLUSIONS: The decision making in patients requiring gamma knife treatment was most likely influenced by the status of the COVID-19 pandemic, while vaccination appeared to attenuate their hesitant behaviors. Patients with pre-treatment neurological deficits and high co-morbidity undergoing the gamma knife treatment were less affected by the COVID-19 pandemic.

Stereotactic radiosurgery with Cyberknife®: first case in the United Arab Emirates (a case report).

A 64-year-old gentleman was referred to the department of oncology with severe pain in the right ear radiating to the right side of the face. Imaging revealed a large extra-axial expansile lesion, surrounding and encasing the right cavernous sinus extending to the right middle cranial fossa. The patient consulted several neurosurgeons and was recommended stereotactic radiosurgery with Cyberknife® as the best non-invasive modality. The proximity to the critical structures, such as the brainstem, made it challenging for any surgical approach. The patient completed stereotactic radiosurgery with Cyberknife® and is doing well one month after treatment.

Integration of Telemedicine Consultations into a Tertiary Radiation Oncology Department: Predictors of Treatment Yield and Changes in Patient Population Compared to the Pre-Pandemic Era

The COVID-19 pandemic has proven telemedicine to be an efficient and safe method of healthcare delivery with the potential to increase accessibility for underrepresented groups. Given the anticipated permanence of telemedicine in radiation oncology practice, we aimed to understand the demographic and treatment characteristics of patients presenting for consultation via telemedicine, the predictors of patients opting to receive radiation therapy (RT) at our center, and the differences in patient and treatment characteristics compared to 2019, when consultations were exclusively in person. We included all patients who had telemedicine consultations from March 2020 to February 2021. Treatment yield was calculated by dividing the number of patients who ultimately received RT by the total number of consults. New consultations seen in 2019 were reviewed and compared to the telemedicine cohort. Chi-square tests were used to identify differences. From 2020 to 2021, a total of 1,069 patients had telemedicine consultations (86% video, 14% phone). Most (64%) were male. Median age was 63 years. The most common disease sites included genitourinary (GU) (41%), breast (14%), and CNS (9%). Six-hundred forty-five (60%) had private insurance, while 424 (40%) had Medicare/Medicaid. Patients lived a median of 241 miles (IQR 96-481 miles) from the radiation oncology center. Forty-four percent of telemedicine patients ultimately received RT. These patients underwent photon RT (54%), proton RT (35%), brachytherapy (7%), stereotactic radiosurgery (3%), or intraoperative RT (1%). No differences were noted in age, sex, race/ethnicity, or insurance type between patients who did and did not receive RT. Patients who received RT lived closer to the center (median 287 vs. 189 miles, p<0.001). For patients within 100 miles of our center, 58% received RT, compared to only 32% of those who lived at least 500 miles away. Patients with gynecologic (76%) and hematologic (72%) malignancies were most likely to receive RT. Compared to 2019 when all 6,116 patients were seen in person, treatment yield was lower with telemedicine (67% vs. 44%, p<0.001). Telemedicine patients were more likely to be male (56% vs. 64%, P<0.001), white (93% vs. 95.0%, p=0.024), have private insurance (55% vs. 60%, p=0.0053), have a GU malignancy (24% vs. 41%, p<0.001), and live further from the center (median 241 vs. 139 miles, p<0.001). Patients seen in telemedicine consultations lived further away and were less likely to receive RT at our tertiary care radiation oncology center. Telemedicine visits did not appear to improve healthcare access for underrepresented groups. Further analysis is warranted to identify gaps and opportunities in remote care. [ FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Technological Improvements in Low- and Middle-Income Countries (LMICs): A Review of the Literature and the "Sociedad de Lucha Contra el Cáncer" (SOLCA) Institutional Experience in Neuro-Radiosurgery During the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: Neurosurgery is a medical field that requires specialized professionals and equipment, 2 important but scarce resources in low- and middle-income countries. Our goal was to report our experience with the replacement and implementation of linear accelerators with radiosurgery capabilities at "Sociedad de Lucha Contra el Cáncer" (SOLCA) Hospital in Quito, Ecuador, and give some recommendations for future technological replacements (TRs). METHODS: Two surveys were performed in SOLCA's radiosurgery department, one before the TR was finalized and one after, consisting of an open and multiple-choice questionnaire. Questions focused on the performance of the new equipment, perceptions regarding the training, and the influence of the pandemic on the whole process. In addition, we share our experience regarding the difficulties and benefits of TR at SOLCA. RESULTS: The most-reported limitation was lack of training (48%). By the time of the second survey, 95.2% of the staff had already treated patients or planned a radiosurgical procedure; 42.9% considered training to have been adequate, and 76.2% felt that the pandemic hindered the training process. Currently, 33 radiosurgeries have been done (26 for the central nervous system and 7 stereotactic radiation body therapies). CONCLUSIONS: The TR in SOLCA had similarities with other experiences in low- and middle-income countries, but the pandemic brought additional limitations, mainly complicating the staff training. Nevertheless, those limitations can be resolved with a structured training program and international collaboration. Overall, the benefits obtained from a TR result in exponentially better medical care and accessibility to novel treatments.

Single-fraction stereotactic ablative body radiation therapy for primary and metastasic lung tumor: A new paradigm?

Stereotactic ablative body radiotherapy (SABR) is an effective technique comparable to surgery in terms of local control and efficacy in early stages of non-small cell lung cancer (NSCLC) and pulmonary metastasis. Several fractionation schemes have proven to be safe and effective, including the single fraction (SF) scheme. SF is an option cost-effectiveness, more convenience and comfortable for the patient and flexible in terms of its management combined with systemic treatments. The outbreak of the severe acute respiratory syndrome coronavirus 2 pandemic has driven this not new but underutilized paradigm, recommending this option to minimize patients' visits to hospital. SF SABR already has a long experience, strong evidence and sufficient maturity to reliably evaluate outcomes in peripheral primary NSCLC and there are promising outcomes in pulmonary metastases, making it a valid treatment option; although its use in central locations, synchronous and recurrencies tumors requires more prospective safety and efficacy studies. The SABR radiobiology study, together with the combination with systemic therapies, (targeted therapies and immunotherapy) is a direction of research in both advanced disease and early stages whose future includes SF.

Early-onset symptomatic radiation necrosis after stereotactic radiosurgery in the setting of COVID-19 infection.

In this brief report, we describe the case of a previously healthy 51-year gentleman who was treated with stereotactic radiosurgery to a dose of 12 Gy to a small right-sided vestibular schwannoma. MRI of the brain performed after treatment revealed stable treated disease but subsequently, the patient developed symptomatic COVID-19 based on PCR along with multiple cranial neurologic deficits, including right facial paralysis, hemifacial anesthesia, and anesthesia of the ipsilateral hard palate and tongue. MRI of the brain was repeated and demonstrated radiation necrosis in the adjacent brainstem for which he was treated with Pentoxifylline and Vitamin E, dexamethasone, and Bevacizumab with only partial improvement. The dose-volume metrics of the brainstem from his radiotherapy plan as well as the trajectory of his imaging findings do not match this clinical picture from radiotherapy alone. We review the basic pathogenesis of the inflammatory response to infection from the SARS-CoV-2 virus as well as the pathogenesis of radiation necrosis. Heightened awareness about potential risks with high-dose radiotherapy in patients with symptomatic COVID-19 should be considered.

The Zap-X Radiosurgical System in the Treatment of Intracranial Tumors: A Technical Case Report.

BACKGROUND AND IMPORTANCE: The Zap-X system (Zap Surgical Systems Inc, San Carlos, California) is a radically new surgical robot designed for brain and head and neck radiosurgery. It represents the first new dedicated brain stereotactic radiosurgery platform in almost half a century optimizing the goals of safety, speed, and accuracy. The Zap-X system was used in a required Chinese National Medical Products Administration clinical study. In early January 2020, 2 patients were treated with the Zap-X robot prior to a national COVID-19 lockdown. Both were closely followed via clinical exam and magnetic resonance imaging (MRI) imaging. Prospectively collected data were used to generate this report. CLINICAL PRESENTATION: Two female patients, each harboring either a trigeminal schwannoma or petroclival meningioma, were treated with the Zap-X robot. Respective tumor volumes were 2.60 and 4.02 cm3. A radiation dose of 13 Gy was prescribed to the 50% isodose line. At 8 mo of follow-up, preoperative symptoms were either resolved or stable and MRI imaging demonstrated a 31% and 56% reduction in lesion volume, respectively. In both patients, symptoms improved, and tumor volumes decreased, whereas no major complication was observed. CONCLUSION: Given only 2 patients and short-term follow-up, any conclusions about the safety and efficacy of the Zap-X radiosurgery robot are preliminary. However, in the absence of any other published outcomes to date, this small case series may be of interest to many radiosurgical specialists.

Adaptation of a Gamma Knife Icon stereotactic radiosurgery program in the face of the COVID-19 pandemic.

Objective: The COVID-19 pandemic necessitated drastic and rapid changes throughout the field of radiation oncology, some of which were unique to the discipline of radiosurgery. Guidelines called for reduced frame use and reducing the number of fractions. Our institution implemented these guidelines, and herein we show the resultant effect on patient treatments on our Gamma Knife Icon program. Methods: In early March 2020 we rapidly implemented suggested changes according to ASTRO and other consensus guidelines as they relate to stereotactic radiosurgery in the COVID-19 era. We reviewed the GK Icon schedule at our institution between January 01 and April 30, 2020. We documented age, condition treated, technique (frame vs. mask), and number of fractions. We then tabulated and graphed the number of patients, framed cases, and fractions delivered. Results: Seventy-seven patients were treated on the GK Icon over that period, for a total of 231 fractions. The number of unique patients varied from 18 (April) to 22 (January). Of the 77 patients only 5 were treated using a frame. The number of fractions per month decreased significantly over time, from 70 in January to 36 in April. Likewise, the percentage of single fraction cases increased from 4.5% per month in January to 67% in April. Conclusions: The results presented here show that it is possible to quickly and efficiently change work flows to allow for reduced fractionation and frame use in the time of a global pandemic. Multidisciplinary cooperation and ongoing communication are integral to the success of such programs.

Managing patient flows in radiation oncology during the COVID-19 pandemic : Reworking existing treatment designs to prevent infections at a German hot spot area University Hospital.

PURPOSE: The described work aimed to avoid cancellations of indispensable treatments by implementing active patient flow management practices and optimizing infrastructure utilization in the radiation oncology department of a large university hospital and regional COVID-19 treatment center close to the first German SARS-CoV­2 hotspot region Heinsberg in order to prevent nosocomial infections in patients and personnel during the pandemic. PATIENTS AND METHODS: The study comprised year-to-date intervention analyses of in- and outpatient key procedures, machine occupancy, and no-show rates in calendar weeks 12 to 19 of 2019 and 2020 to evaluate effects of active patient flow management while monitoring nosocomial COVID-19 infections. RESULTS: Active patient flow management helped to maintain first-visit appointment compliance above 85.5%. A slight appointment reduction of 10.3% daily (p = 0.004) could still significantly increase downstream planning CT scheduling (p = 0.00001) and performance (p = 0.0001), resulting in an absolute 20.1% (p = 0.009) increment of CT performance while avoiding overbooking practices. Daily treatment start was significantly increased by an absolute value of 18.5% (p = 0.026). Hypofractionation and acceleration were significantly increased (p = 0.0043). Integrating strict testing guidelines, a distancing regimen for staff and patients, hygiene regulations, and precise appointment scheduling, no SARS-CoV­2 infection in 164 tested radiation oncology service inpatients was observed. CONCLUSION: In times of reduced medical infrastructure capacities and resources, controlling infrastructural time per patient as well as optimizing facility utilization and personnel workload during treatment evaluation, planning, and irradiation can help to improve appointment compliance and quality management. Avoiding recurrent and preventable exposure to healthcare infrastructure has potential health benefits and might avert cross infections during the pandemic. Active patient flow management in high-risk COVID-19 regions can help Radiation Oncologists to continue and initiate treatments safely, instead of cancelling and deferring indicated therapies.

Adaptations in Radiosurgery Practice during COVID Crisis.

BACKGROUND: The world is in the midst of the COVID crisis, which has forced the neurosurgical community to change its practices. OBJECTIVE: To advocate the necessary adaptations in radio surgical practices to effectively manage the radio surgical patients, resource utilization, and protecting the healthcare provider during the COVID pandemic. MATERIAL AND METHODS: In addition to the literature review, pertinent recommendations are made in respect to the gamma knife radiosurgery (GKRS). RESULTS: Every patient presenting to GKRS treatment should be considered as a potential asymptomatic COVID carrier. Patients should be categorized based on the priority (urgent, semi-urgent, or elective) on the basis of pathological and clinical status. The only urgent indication is a non-responding or enlarging cerebral metastasis. There is a high risk of aerosol dispersion during gamma radiation delivery in the gamma gantry. CONCLUSION: These recommendations should be used to minimize the chances of pathogenic exposure to the patient and caregivers both.

The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?

INTRODUCTION: Severe acute respiratory syndrome, coronavirus 2 (SARS-COV 2) has inexplicably and irreversibly changed the way of neurosurgery practice. There has been a substantial reduction in neurosurgical operations during the period of lockdown. The lockdown might be the most effective measure to curtail viral transmission. Once we return to the normalization of the lifestyle, there will be a backlog of unoperated pending cases along with the possibility of further spread of the coronavirus. METHODS: We reviewed the available literature and protocols for neurosurgical practice in different geographic locations. We drafted a consensus statement based on the literature and protocols suggested by the World Health Organization (WHO) and various professional societies to prevent the spread of SARS-COV2 while streamlining the neurosurgical practice. RESULTS: The consensus statement suggests the patient triage, workflow, resource distribution, and operational efficacy for care providers at different stages of management. The priority is set at personal protection while ensuring patients' safety, timely management, and capacity building. We performed a detailed subsection analysis for the management of trauma and set up for COVID-free hospitals for simultaneous management of routine neurosurgical indications. In this time of medicolegal upheaval, special consent from the patients should be taken in view of the chances of delay in management and the added risk of corona infection. The consensus statements are applicable to neurosurgical setups of all capacities. CONCLUSION: Along with the glaring problem of infection, there is another threat of neurosurgery emergency building up. This wave may overwhelm the already stretched systems to the hilt. We need to flatten this curve while avoiding contagion. These measures may guide neurosurgery practitioners to effectively manage patients ensuring the safety of caregivers and care seekers both.