Ultrasonography During Surgery to Approach Cerebral Metastases: Effect on Karnofsky Index Scores and Tumor Volume.

BACKGROUND: The goals of treating a cerebral metastasis (CM) are to achieve local control of the disease and to improve patient quality of life. The aim of this study was to analyze the effect of conventional surgery supported by intraoperative ultrasound (IOUS) to approach a CM. To perform this analysis, we determined the postoperative Karnofsky Performance Status Scale (KPS) scores and tumor resection grades. METHODS: Patients with a CM diagnosis were included in this study. Surgical treatment was either supported or not by IOUS. Pre- and postoperative KPS scores were determined by the oncology team, and cerebral tumor volume was estimated through pre- and postoperative magnetic resonance imaging. The surgical team determined whether it was possible to perform a total CM resection. RESULTS: There were 78 patients treated using surgical management (35 with and 43 without IOUS). In the IOUS group, the postoperative KPS scores were higher (80 vs. 70, respectively; P = 0.045) and the KPS evolution was superior (P = 0.036), especially in the following subgroups: difficulty of tumor resection ranking score <4 (P = 0.037), tumor in an eloquent area (P = 0.043), tumor not associated with vessels or nerves (P = 0.007), and solitary lesions (P = 0.038). The residual tumor volume was lower in the IOUS group (9.5% and 1.6 mm3 vs. 30.8% and 9 mm3, respectively; P = 0.05). In patients with a KPS score ≥70, 62% of them had <10% residual tumors (76% in the IOUS group and 45% in the non-IOUS group; P = 0.032; odds ratio, 3.8). CONCLUSIONS: IOUS may improve postoperative KPS scores and decrease residual tumor volumes in CM surgeries. These findings should be confirmed in future studies.

Carcinoma de células renales: hipernefroma. Presentación de un caso / Carcinoma of renal cells: hypernephroma. Case presentation

Se presentó el caso clínico de una mujer de 51 años de edad, fumadora inveterada, con antecedentes de anemia de varios años de evolución y trastornos de la personalidad, tratados en ocasiones con fenotiacinas, que comienza a referir desde hace un mes episodios recurrentes, caracterizados por trastornos del estado de ánimo con elementos melancólicos. Estos problemas fueron percibidos por sus compañeros de trabajo, pero sin darle la debida importancia hasta que, en una mañana, la paciente despierta con una hemiparesia izquierda. Se constató por tomografía axial computarizada una imagen de tumoración cerebral valorada por Neurocirugía, y se sometió a tratamiento conservador por parte de dicha especialidad con radiaciones. Mejorado el cuadro, la paciente fue dada de alta con seguimiento ambulatorio hasta que regresa al hospital dos meses después con fiebre de doce días de duración, vómitos en proyectil, cefalea y estado confusional agudo, decidiéndose su reingreso en el hospital militar de Matanzas. La paciente falleció y en la autopsia se constató un adenocarcinoma renal derecho, pobremente diferenciado con metástasis cerebrales múltiples.

We present the clinical case of a woman aged 51 years, inveterate smoker, with antecedents of anemia of several years of evolution and personality disorders treated with phenothiazines, referring recurrent episodes characterized by moods disorders with melancholic elements which began a month ago. These problems were perceived by her coworkers, but they did not give importance to that until one day the patient awaked with a left hemiparesis. An image of a cerebral tumor was found by axial tomography assessed by Neurosurgery, and subjected to conservative treatment with radiation by that specialty. After she got better, the patient was discharged until she returned to hospital two months later with fever lasting 12 days, deciding her readmission in the Matanzas military hospital. The patient died and it was found a right renal adenocarcinoma, poorly differentiated with multiple cerebral metastases in the autopsy.

Actualización del tratamiento multimodal para la metástasis cerebral única. Revisión sistemática cualitativa / Update of multimodal treatment for single brain metastasis. Systematic qualitative review

El tratamiento de la Enfermedad Metastásica Cerebral única es paliativo y multimodal desconociéndose con certeza la modalidad o combinación terapéutica óptima. Se planteó como objetivo determinar las diferencias entre la Radioterapia Holocraneal, Radiocirugía, y Resección Quirúrgica en cuanto a la Sobrevida Global, Sobrevida Con Independencia Funcional, Control Local, Muerte Neurológica y Neurocognición en los pacientes con enfermedad metastásica cerebral única con tumor primario controlado. Se realizó un estudio retrospectivo del tipo revisión sistemática cualitativa. Se incluyeron Ensayos Clínicos Aleatorizados que compararon la Cirugía (con o sin Radioterapia Holocraneal), con la Radiocirugía (con o sin Radioterapia Holocraneal) en la Enfermedad Metastásica Cerebral Única independientemente de la localización del tumor primario. La búsqueda encontró inicialmente 971 artículos, de ellos 19 Ensayos Clínicos Aleatorizados. Al aplicar la herramienta de riesgo de sesgos de Cochrane se derivó una muestra de 14 Ensayos Clínicos que presentaron bajo riesgo de sesgos. La combinación de RQ y RTH ofreció mayor SG que la RTH sola. La combinación de RTH y RC ofreció un mejor CL que la RQ y RTH. La combinación de RTH Y RC ofreció un mejor CL y SG que la RTH sola. No se encontraron diferencias significativas entre la RTH y RC versus RC sola. Los resultados en cuanto a la neurocognición y SIF fueron inconsistentes. El tratamiento óptimo de los pacientes con EMC aún no está bien definido constituyendo aún un tema controvertido.

The treatment of Isolated Cerebral Metastatic Disease is both multimodal and palliative. At present, the optimal treatment protocol is unknown. The objective of the present study was to determine outcome differences between Whole Brain Radiotherapy (WBRT), Radiosurgery (RS), and Surgical Resection (SR) or a combination of them, regarding Global Survival, Functional Independent Survival, Local Control, Neurological Death & Cognitive Status in patients with a unique cerebral metastasis and a controlled primary tumor. A retrospective study with a systematic qualitative literature review was performed. Randomized clinical trials comparing surgery (with or without whole brain radiotherapy), disregarding the localization of the primary tumor, were searched, resulting in 971 studies, only 19 of them being randomized. After applying Cochrane´s Risk of Bias Tool, only 14 studies showed a low risk of bias. The combination of SR & WBRT showed a longer survival, while WBRT & RS showed a better local control when compared with SR & WBRT. No statistical differences where found between WBRT & RS versus RS alone. Results regarding Cognitive Status & Functional Independent Survival were inconsistent. The optimal treatment in Isolated Metastatic Cerebral Disease still remains controversial.

Metástase cerebral como manifestação inicial de adenocarcinoma de próstata / Cerebral metastases as the first manifestation of prostatic adenocarcinoma

O acometimento do sistema nervoso central por neoplasia primária de próstata é raro. Cerca de 2% a 4% dos pacientes com adenocarcinoma de próstata disseminado apresentam metástases parenquimatosas para cérebro ou medula espinhal. A metástase cerebral por adenocarcinoma de próstata ocorre por disseminação hematogênica a distância, somenteapós comprometimento dos ossos e pulmões. Os autores descrevem dois casos de metástases cerebrais como manifestação inicial de adenocarcinoma de próstata, sem acometimento clínico de outros órgãos. Discutem sua via de disseminação e prognóstico. Sem dúvida, pode haver lesão em outros órgãos que não se manifestaram clinicamente e apresentam um péssimo prognóstico.

Intracranial metastases from adenocarcinoma of the prostate is rare. The incidence of metastatic prostatic cancer in the brain or spinal cord is approximately 2 to 4 percent in large series. Brain metastases tases from prostatic adenocarcinoma can be explained by distance hematogenic widespread after secundary focus in the bone or lung. The authors report two patients with intracranial metastases as the first manifestation of prostate cancer, with no symptoms in other sites.