Visual Symptoms Outcomes in Cavernous Sinus Radiosurgery and a Systematic Review.

Introduction The complex anatomy of the cavernous sinus confers a true challenge when it comes to safe tumor resection. Due to its non-invasive nature, stereotactic radiosurgery (SRS) is expected to have lower mortality and morbidity rates than microsurgery. The purpose of this study was to evaluate clinical results regarding visual symptoms after SRS for benign tumors invading the cavernous sinus. We also conducted a systematic literature review to provide a robust analysis regarding visual outcomes. Methods The study included 58 patients (43 women and 15 men; mean age: 52 years) with benign tumors invading the cavernous sinus (27 pituitary adenomas and 31 meningiomas) who underwent SRS with different platforms between August 2011 and December 2021. Of these, 26 patients underwent surgery before SRS, and the remaining 32 had SRS as first-line therapy. We identified symptoms involving cranial nerves (CN) II, III, IV, and VI in 38 patients at the time of SRS. We conducted a systematic review to identify all original studies assessing visual outcomes. We searched PubMed, the Latin American and Caribbean Health Sciences Literature index, and Google Scholar using the Medical Subject Heading search terms "radiosurgery" and "cavernous sinus" for valid studies published until January 31, 2022. Results Regarding pituitary adenomas, median tumor volume was 2.05 cc, 3.12 cc, and 2.39 cc for Gamma Knife (GK), CyberKnife (CK), and tomotherapy (Tomo), respectively. Median doses were 14 Gy for GK, 17 Gy for CK, and 15 Gy for Tomo. For meningiomas, median tumor volume was 10.2 cc, 2.62 cc, and 16.3 cc for GK, CK, and Tomo, respectively. The median dose was 14 Gy for GK, 14 Gy for CK, and 14.5 Gy for Tomo. The overall tumor control rate was 100% with a median follow-up of 33 months (range: 6-128 months). A reduction of >30% in total tumor size per the Response Evaluation Criteria in Solid Tumors (RECIST) classification was documented in seven patients (RECIST II; 12.1%), 51 patients (87.9%) had stable disease (RECIST III), and no increase in tumor volume was documented in any patient. Visual symptoms improved in 51.7% of patients. In the systematic review, the mean visual improvement was 36% (range: 25.8-42.5%). Conclusion SRS is an effective treatment for benign tumors invading the cavernous sinus. In this series, patients who underwent SRS as a primary treatment showed improvement in pre-existing cranial neuropathy and visual symptoms. Given the natural history of these tumors, which tend to grow and cause visual alternations, treating asymptomatic patients is a feasible approach worth considering for the appropriate patients.

Multiplatform Radiosurgery for Intracranial Meningiomas and Dose to the Dural Tail.

Introduction Meningiomas are extra-axial central nervous system tumors. Complete resection is often curative with macroscopically complete removal of the tumor, excision of its dural attachment, and any abnormal bone. Radiosurgery is also an option for high-risk patients or in patients with surgically residual disease. Dural tail is a typical radiological sign on contrast-enhanced MRI; it can contain tumor cells or be a reaction due to vascular congestion and edema. Radiosurgical planning treatment varies regarding the identification and coverage of the dural tail. This study aimed to retrospectively analyze a series of 143 patients with WHO Grade I meningiomas treated with different radiosurgical platforms, and dosing parameters focused on planning and dose delivery to the dural tail. Methods From February 2011 to July 2020, 143 patients with histologically confirmed or radiologically assumed WHO Grade I meningiomas were treated using rotating gamma-ray Infini™ (Gamma [MASEP Medical Science Technology Development Co., Shenzhen, China]), TomoTherapy® (Tomo [Accuray Inc., Sunnyvale, CA]), and CyberKnife® (CK [Accuray Inc.]). All plans were retrospectively reviewed to establish the maximum distance (MaxDis) from the prescription dose to the end of the dural tail and the minimum dose at the dural tail (MinDoseT) at this point. We also established the midpoint distance (MPDis) from the prescription dose to MaxDis and the dose at this point (MPDose). Plans were further distinguished when the physician intended to cover the dural tail versus when not. Patients and tumor response were assessed by imaging and clinical and phone call evaluations. Results Of the 143 patients, 81 were treated using Gamma, 34 using Tomo, and 28 using CK. Eighty patients were eligible for follow-up, of whom 58 (72.5%) had an unmistakable dural tail sign. Median follow-up was 1,118 days (range 189-3,496), mean age was 54.5 (range 19-90), and 61 were women, and 19 were men. Overall tumor volume was 6.5 cc (range 0.2-59); mean tumor volumes by different platforms were 2.4, 9.45, and 8 cc; dose prescribed and mean tumor coverage were 14 Gy and 92%, 14.5 Gy and 95%, and 14 Gy and 95.75% with Gamma, Tomo, and CK, respectively. The dural tail was drawn and planned with an attempt to treat in 18 patients (31%); the mean MaxDis, MinDoseT, MPDis, and MPDose were 9.0 mm, 2 Gy, 4.5 mm, and 10.6 Gy, respectively. At last follow-up, tumor control was achieved in 96% of patients for the whole series, and there were no statistical variations regarding tumor volume, dose, conformality, or control when stereotactic radiosurgery was used to cover the dural tail versus when it was not (p=0.105). One patient experienced a Grade 4 Radiation Therapy Oncology Group toxicity as an adverse radiation effect that required surgery, and 11 (7.6%) experienced a Grade 1 toxicity. Conclusions This is our preliminary report regarding the efficacy of radiosurgery for meningiomas using diverse platforms at three years of follow-up; the results regarding tumor control are in accordance with the published literature as of this writing. A conscious pursuit of the dural tail with the prescription dose has not proven to provide better tumor control than not doing so - even small areas of the tumor uncovered by the prescription dose did not alter tumor control at current follow-up. The doses delivered to these uncovered areas are quite significant; further follow-up is necessary to validate these findings.

Autoimmune response against myocardial tissue in Chagas' disease

Hacen aproximadamente 12 años se demostró en el suero de individuos chagásicos la presencia de un anticuerpo que, por inmunofluorescencia indirecta, reacciona con endocardio, vasos sanguíneos e intersticio de músculo cardíaco (anticuerpo EVI). En los primeros trabajos, se expresó erróneamente que dicha reactividad tenía carácter de autoanticuerpo; más recientemente se determinó su naturaleza heterófila. El propósito del presente trabajo fue determinar qué sistema está involucrado en la respuesta autoinmune humoral contra tejido cardíaco en la enfermedad de Chagas, su prevalencia y especificidad. La presencia de anticuerpos que reaccionan con cortes por criostato de corazón humano grupo 0 fue investigada por la técnica de inmunofluorescencia indirecta en pacientes chagásicos y controles. Los resultados positivos fueron hallados con la siguiente prevalencia: cardiopatía chagásica crónica: 22/34 (64%); infectados asintomáticos: 16/42 (38%); infectados sin datos clínicos: 19/43 (44%); cardiopatías congénitas (pre-cirugía); 0/17 y post-cirugía: 3/5; valvulopatía reumática y cardiopatía isquémica: 7/24 (34%); lupus eritematoso sistémico: 6/15 (40%); artritis reumatoidea: 5/17 (29%); osteoartritis (pacientes en la 6ª y 7ª década de vida): 4/19 (21%); controles normales (ciudad de Buenos Aires): 2/29 (7%); controles normales (provincia de Jujuy): 3/16 (19%). La imagen observada fue intracelular siguiendo las estrías. Los experimentos de absorción con glóbulos rojos de cobayo y con proteínas purificadas de músculo demostraron que la reacción intracelular es independiente del anticuerpo EVI, y es removida con miosina. En un caso, la autorreactividad fue confirmada entre una biopsia de miocardio y el suero del mismo paciente. Los títulos de reactividad de los anticuerpos oscilaron entre 1:15 y 1:60. La IgG estuvo siempre involucrada y en algunos casos también la IgM. El anticuerpo no fija C3. El presente estudio demuestra la existencia de una verdadera reacción autoinmune con miocardio en la enfermedad de Chagas. Su significado debe ser aún demostrado, pero podría ser secundario al daño tisular

Autoimmune response against myocardial tissue in Chagas disease

Hacen aproximadamente 12 años se demostró en el suero de individuos chagásicos la presencia de un anticuerpo que, por inmunofluorescencia indirecta, reacciona con endocardio, vasos sanguíneos e intersticio de músculo cardíaco (anticuerpo EVI). En los primeros trabajos, se expresó erróneamente que dicha reactividad tenía carácter de autoanticuerpo; más recientemente se determinó su naturaleza heterófila. El propósito del presente trabajo fue determinar qué sistema está involucrado en la respuesta autoinmune humoral contra tejido cardíaco en la enfermedad de Chagas, su prevalencia y especificidad. La presencia de anticuerpos que reaccionan con cortes por criostato de corazón humano grupo 0 fue investigada por la técnica de inmunofluorescencia indirecta en pacientes chagásicos y controles. Los resultados positivos fueron hallados con la siguiente prevalencia: cardiopatía chagásica crónica: 22/34 (64%); infectados asintomáticos: 16/42 (38%); infectados sin datos clínicos: 19/43 (44%); cardiopatías congénitas (pre-cirugía); 0/17 y post-cirugía: 3/5; valvulopatía reumática y cardiopatía isquémica: 7/24 (34%); lupus eritematoso sistémico: 6/15 (40%); artritis reumatoidea: 5/17 (29%); osteoartritis (pacientes en la 6¬ y 7¬ década de vida): 4/19 (21%); controles normales (ciudad de Buenos Aires): 2/29 (7%); controles normales (provincia de Jujuy): 3/16 (19%). La imagen observada fue intracelular siguiendo las estrías. Los experimentos de absorción con glóbulos rojos de cobayo y con proteínas purificadas de músculo demostraron que la reacción intracelular es independiente del anticuerpo EVI, y es removida con miosina. En un caso, la autorreactividad fue confirmada entre una biopsia de miocardio y el suero del mismo paciente. Los títulos de reactividad de los anticuerpos oscilaron entre 1:15 y 1:60. La IgG estuvo siempre involucrada y en algunos casos también la IgM. El anticuerpo no fija C3. El presente estudio demuestra la existencia de una verdadera reacción autoinmune con miocardio en la enfermedad de Chagas. Su significado debe ser aún demostrado, pero podría ser secundario al daño tisular (AU)