Metastatic renal cell carcinoma to the brain: optimizing patient selection for gamma knife radiosurgery.

INTRODUCTION: The effects of single-fraction gamma knife radiosurgery (sf-GKRS) on patients with renal cell carcinoma (RCC) brain metastases (BM) in the era of targeted agents (TA) and immune checkpoint inhibitors (ICI) are insufficiently studied. METHODS AND MATERIALS: Clear cell metastatic RCC patients treated with sf-GKRS due to BM in 2005-2014 at three European centres were retrospectively analysed (n = 43). Median follow-up was 56 months. Ninety-five percent had prior nephrectomy, 53% synchronous metastasis and 86% extracranial disease at first sf-GKRS. Karnofsky performance status (KPS) ranged from 60 to 100%. Outcome measures were overall survival (OS), local control (LC) and adverse radiation effects (ARE). RESULTS: One hundred and ninety-four targets were irradiated. The median number of targets at first sf-GKRS was two. The median prescription dose was 22.0 Gy. Thirty-seven percent had repeated sf-GKRS. Eighty-eight percent received TA. LC rates at 12 and 18 months were 97% and 90%. Median OS from the first sf-GKRS was 15.7 months. Low serum albumin (HR for death 5.3), corticosteroid use pre-sf-GKRS (HR for death 5.8) and KPS < 80 (HR for death 9.1) were independently associated with worse OS. No further prognostic information was gleaned from MSKCC risk group, synchronous metastasis, age, number of BM or extracranial metastases. Other prognostic scores for BM radiosurgery, including DS-GPA, renal-GPA, LLV-SIR and CITV-SIR, again, did not add further prognostic value. ARE were seldom symptomatic and were associated with tumour volume, 10-Gy volume and pre-treatment perifocal oedema. ARE were less common among patients treated with TA within 1 month of sf-GKRS. CONCLUSIONS: We identified albumin, corticosteroid use and KPS as independent prognostic factors for sf-GKRS of clear cell RCC BM. Studies focusing on the prognostic significance of albumin in sf-GKRS are rare. Further studies with a larger number of patients are warranted to confirm the above analytical outcome. Also, in keeping with previous studies, our data showed optimal rates of local tumour control and limited toxicity post radiosurgery, rendering GKRS the tool of choice in the management of RCC BM.

Adaptive radiosurgery based on two simultaneous dose prescriptions in the management of large renal cell carcinoma brain metastases in critical areas: Towards customization.

BACKGROUND: The long-term benefits of local therapy in metastatic renal cell carcinoma (mRCC) have been widely documented. In this context, single fraction gamma knife radiosurgery (SF-GKRS) is routinely used in the management of brain metastases. However, SF-GKRS is not always feasible due to volumetric and regional constraints. We intend to illustrate how a dose-volume adaptive hypofractionated GKRS technique based on two concurrent dose prescriptions termed rapid rescue radiosurgery (RRR) can be utilized in this particular scenario. CASE DESCRIPTION: A 56-year-old man presented with left-sided hemiparesis; the imaging showed a 13.1 cc brain metastasis in the right central sulcus (Met 1). Further investigation confirmed the histology to be a metastatic clear cell RCC. Met 1 was treated with upfront RRR. Follow-up magnetic resonance imaging (MRI) at 10 months showed further volume regression of Met 1; however, concurrently, a new 17.3 cc lesion was reported in the boundaries of the left frontotemporal region (Met 2) as well as a small metastasis (<1 cc) in the left temporal lobe (Met 3). Met 2 and Met 3 underwent RRR and SF-GKRS, respectively. RESULTS: Gradual and sustained tumor ablation of Met 1 and Met 2 was demonstrated on a 20 months long follow- up. The patient succumbed to extracranial disease 21 months after the treatment of Met 1 without evidence of neurological impairment post-RRR. CONCLUSION: Despite poor prognosis and precluding clinical factors (failing systemic treatment, eloquent location, and radioresistant histology), RRR provided optimal tumor ablation and salvage of neurofunction with limited toxicity throughout follow-up.

Surgical removal of spinal mass lesions with open door laminoplasty.

OBJECTIVE: The open door laminoplasty technique has been previously used to treat cervical spondylotic myelopathy. We adapted this technique for the removal of spinal tumors all along the spinal axis. METHODS: Between January 2002 and January 2003, 17 patients with various intraspinal lesions underwent open door laminoplasty. The thoracal level was involved in 10 cases, the cervical level in 3 patients and the lumbar level in 4. Location of the tumor was intradural-intramedullary in 7, intradural-extramedullary in 6 and extradural in 4 patients. The histological diagnoses were 4 astrocytomas, 2 meningiomas, 3 neurinomas, 2 ependymomas and one case each with Ewing's sarcoma, metastasis, abcess, hemangioblastoma, arachnoid cyst and lipoma. RESULTS: All lesions were exposed using the open door laminoplasty technique and were successfully removed for intraspinal mass lesions. An average of 3.7 level laminoplasty was performed. Neither spinal malalignment on the coronal plane nor displacement of bone flap (laminoplasty flap) were observed on postoperative CT and MR examinations. No complications due to laminoplasty were encountered. The mean follow-up was 30 months (range 22-48 months). CONCLUSION: Open door laminoplasty is a simple procedure and has two main advantages over the classical laminectomy procedure; a lower incidence of spinal deformities with or without neurological deficits and an absence of epidural scar tissue. This procedure can be used in all spinal cases with intraspinal mass lesions.

Dexmedetomidine-based versus fentanyl-based total intravenous anesthesia for lumbar laminectomy.

BACKGROUND: The present study was designed to show the effects of dexmedetomidine infusion with loading dosage on perioperative hemodynamics, propofol consumption, and postoperative recovery when used for general anesthesia in patients undergoing spinal laminectomy. METHODS: Fifty American Society of Anesthesiologists (ASA) I-II patients were randomised into two groups. Group D received dexmedetomidine 0.6 microg kg(-1) as bolus before induction and 0.2 microg kg(-1) h(-1) by infusion. Group F received fentanyl 1 microg kg(-1) as bolus before induction and 0.5 microg kg(-1) h(-1) by infusion. Signs of inadequate analgesia, defined as an increase in heart rate and mean arterial pressure (MAP) 20% above the baseline, were managed by increasing or decreasing the dosage of dexmedetomidine and fentanyl. Statistical analysis was performed with student t, chi-squared and Fisher's exact tests. RESULTS: The maintenance dosage was 0.64+/-0.06 microg kg(-1) h(-1) for fentanyl in Group F and 0.31+/-0.08 microg kg(-1) h(-1) for dexmedetomidine in Group D. MAP values in Group D were significantly higher than in Group F only after intubation. Before and after extubation, MAP values in Group F were significantly higher than those in Group D. There was no statistical difference in heart rate between the groups. Propofol dosages for induction (1.40+/-0.48 mgkg(-1)) and maintenance of anesthesia (2.03+/-0.41 mg kg(-1)) were lower with dexmedetomidine. Extubation time and postanesthesia care unit discharge time were similar in both groups. The fentanyl group patients required supplemental analgesia earlier than the dexmedetomidine group (34.8+/-1.35 min vs 60.4+/-1.04 min). Postoperative nausea and vomiting were significantly higher in Group F. CONCLUSION: In conclusion, propofol-dexmedetomidine is suitable for patients undergoing elective spinal laminectomy and provides stable perioperative hemodynamic responses. Propofol-fentanyl medication requires a higher dosage of postoperative analgesics and causes frequent postoperative nausea and vomiting compared with propofol-dexmedetomidine.