Hypofractionated Stereotactic Radiation Therapy to the Resection Bed for Intracranial Metastases.

PURPOSE: To retrospectively report the outcomes of a large multicenter cohort of patients treated with surgery and hypofractionated stereotactic radiation therapy (HFSRT) to the resection cavities of brain metastases (BMs). METHODS AND MATERIALS: Between March 2008 and February 2015, 181 patients with no prior whole-brain radiation therapy (WBRT) were treated by HFSRT to the surgical bed of BM at the dose of 33 Gy (3 × 11 Gy). The primary endpoint was local control. Secondary endpoints were distant brain control, overall survival (OS), risk of radionecrosis, and leptomeningeal disease (LMD). RESULTS: Of the 189 resected lesions, 44% were metastatic from a non-small cell lung cancer primary tumor, and 76% of patients had a single BM at the time of treatment. With a median follow-up of 15 months, the 6- and 12-month local control rates were 93% and 88%, respectively. On multivariate analysis, planning target volume (P=.005), graded prognostic assessment score (P=.021), and meningeal contact of BM (P=.032) were predictive of local failure. The 6- and 12-month distant brain control rates were 70% and 61%, respectively. Twenty-six patients (14%) developed signs of LMD at a median time of 3.8 months. The preoperative tumor volume was predictive of LMD (P=.029). The median OS was 17 months. The 6-, 12-, and 24-month OS rates were 79%, 62%, and 39%, respectively. Recursive partitioning analysis class 3 (P=.02), piecemeal resection (P=.017), and an increasing number of BMs (P<.01) were independent unfavorable prognostic factors for OS. Fifty-four patients (30%) were subsequently treated with salvage WBRT at a median time of 6.5 months, and 41% were reirradiated with SRT. Radionecrosis occurred in 19% of cases at a median time of 15 months and was associated with the infratentorial location of the BM (P=.0025). CONCLUSIONS: This study demonstrated the safety and efficacy of a 3 × 11 Gy HFSRT regimen for the irradiation of BMs resection cavities. It was an alternative to adjuvant WBRT.

Neurosurgical Emergency Transfers: An Analysis of Deterioration and Mortality.

BACKGROUND: Neurological deterioration and mortality are frequent in neurosurgical patients transferred to tertiary centers, but the precise predictors leading to them are unclear. OBJECTIVE: To analyze and quantify risk factors predicting deterioration and death in neurosurgery transfers. METHODS: A consecutive review of all transfers with cranial pathology to a tertiary academic neurosurgery service was performed over a 2-year period. Risk factors including demographics, medical comorbidities, hydrocephalus, anticoagulant use, transfer diagnosis, Glasgow Coma Scale score, and transfer time were reviewed. RESULTS: A total of 1429 transfers were studied, including 154 (10.8%) instances of neurological decline in transit and 99 mortalities (6.9%). On multivariate analysis, significant predictors of decline were hydrocephalus ( P = .005, odds ratio [OR] 2) and use of clopidogrel ( P = .003, OR 4.3), warfarin ( P = .004, OR 2.6), or other systemic anticoagulants ( P < .001, OR 10.1). Age ( P = .004), hydrocephalus ( P = .006, OR 2.1), renal failure ( P = .05, OR 2.3), and use of clopidogrel ( P = .003, OR 4.6) or warfarin ( P = .03, OR 2.3) were found to be predictive of death. Analysis by transfer diagnosis found patients with intracerebral hemorrhage had the highest incidence of mortality (12.7%, P = .003, OR 2). Patients who ultimately died were transferred faster than survivors, but this did not achieve significance. CONCLUSION: Neurosurgery patients are vulnerable to deterioration in transit and exhibit several patterns predictive of mortality. Hydrocephalus, use of clopidogrel and warfarin, and intracerebral hemorrhage are each independently associated with elevated risk of deterioration and death.

Olfactory ensheathing cell tumour: case report and literature review.

Olfactory ensheathing cell tumour (OECT) and olfactory groove schwannoma (OGS) are among the rarest intracranial tumour types that develop within anterior cranial fossa. These tumours share several similarities, including radiological and histological aspects, and only immunohistochemical staining can differentiate between them. We report a case of OECT occurring in a 28-year-old woman with a history of complex partial seizures, emotional lability and anosmia. Radiological features showed a predominantly left subfrontal extra-axial mass. Total excision of the tumour, connected to the cribriform plate and contiguous to the left olfactory bulb, was performed. Histological examination suggested an atypical schwannoma; however, immunohistochemical staining was strongly positive for S-100 protein but negative for both epithelial membrane antigen (EMA) and CD 57 (Leu-7). The final diagnosis was olfactory ensheathing cell tumour. We describe the third case of OECT and emphasize the important role of immunohistochemical staining in diagnosis: awareness of this entity, and use of immunohistochemistry help to distinguish it from OGS.