Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is the best imaging study to differentiate between recurrent glioblastoma and pseudoprogression?
Chemo-radiation-induced pseudoprogression (Psp) and/or necrosis present with MRI findings indistinguishable from tumor recurrence on conventional contrast-enhanced MRI. However, while early progressive disease (ePD) indicates treatment failure and necessitates a change in therapy, Psp indicate succe...
Do you include the dural tail when treating benign meningioma with SRS?
Usually not; it is not common for the dural tail to be directly involved by tumor; however, in some cases, one can visualize tumor approaching the dural tail as distinct from the vascular dural tail, in which case the tumor of course needs to be targeted
Is it acceptable to treat glioblastoma with upfront SRS instead of fractionated external beam RT?
There is good prospective randomised data in this setting for using hypofractionated RT alone (34/10 fractions or 40/15 fractions) or Temodar alone (if MGMT methylated). If the goal is palliation and QOL improvement, either of the two based on the clinical situation is a viable option.There is no go...
What is the most appropriate adjuvant treatment for a gross totally resected recurrent spinal meningioma that has not received prior radiation?
Our CNS radonc group discussed options of therapy in this scenario at our faculty QA meeting. In general, it was acknowledge that options of management would be case specific, and could vary given the rarity of these cases and the limited number of published institutional series. Overall, our group ...
Should whole brain radiation therapy and orbital radiation therapy be administered in situations of ocular B-cell lymphoma recurrence 2 years after primary CNS lymphoma treated with intrathecal methotrexate and no prior cranial irradiation?
There are multiple small series showing good a salvage rate with radiation therapy with acceptable morbidity for patients who have failed prior MTX. The outcome is dictated by age and extent of disease and accordingly one can plan for a palliative or definitive dose.
Should post-op RT be delayed for children < 3yo after a GTR resection for a posterior fossa or supratentorial ependymoma?
Standard of care for a GTR posterior fossa ependymoma of any histologic grade is immediate adjuvant radiotherapy. If a STR is encountered, chemotherapy may be considered to try and facilitate a second look surgery. The current protocol allows patients with supratentorial ependymomas that have receiv...
What is the value and potential morbidity of second look surgery in patients with sub-totally resected ependymoma?
Since gross resection of ependymoma is associated with improved prognosis, chemotherapy is frequently used to render sub-totally resected ependymoma potentially resected totally during second look surgery (thereby improving prognosis). One of the main reasons that the tumor in the posterior fossa is...
Should we be integrating tumor treating fields into standard glioblastoma treatment?
The EF14 trial preliminary results were just published in JAMA and demonstrate an improvement in both PFS and OS for the experimental arm, and the device has received FDA approval. In the neuro-oncology community, there is still anticipation regarding the final results (the entire cohort outcome dat...
Is SBRT an appropriate treatment for recurrent and unresectable spinal ependymoma?
We have reirradiated a handful of patients who had 45-54Gy to the spinal cord 5-12 years ago with another course of RT 50Gy/25 to the cord without any neurologic sequelae--this is unpublished (we are working on it). We have also reirradiated small recurrences after a full course of RT to the spinal ...
For definitive fractionated RT of meningioma (presumed) without biopsy is it always necessary to treat edema evident on MRI Flair sequence?
Edema with meningioma is a complex issue, but appears in the vast majority of cases not associated with cerebral invasion by meningothelial cells. Clearly meningiomas can on occasion be brain invasive. This is now carefully defined as a WHO 2016 grade II criterion, but edema has not been shown to be...