Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
For a recurrent grade 1 meningioma after resection, do you favor SRS or fractionated RT?
I generally prefer SRS, unless the recurrence is not seen as a discrete lesion, or is in a location in which I would be overly concerned about toxicity with SRS, or toxicity if the cavity needed to be treated with conventionally fractionated radiation in the future. Perhaps if the recurrence develop...
Do you ever use bevacizumab in combination with standard radiation and temozolomide in the first-line setting for patients with glioblastoma?
Two clinical trials (AVAGLIO and RTOG 0825) used bevacizumab (Avastin) along with standard temozolomide and radiation therapy for newly diagnosed glioblastoma. While they did not see improved OS, they did see improved PFS. In an evaluation of AVAGLIO, for those patients who did not go on to receive ...
Is there a role for hyperbaric oxygen treatment concurrent with radiotherapy in the treatment of pediatric glioblastoma?
HBO has been used primarily in the treatment of radiation induced injury in patients with controlled intracranial disease. The application of HBO in the post-treatment setting has been limited by fears of latent reactivation of tumor metabolism and therefore progression. There are countless manuscri...
Do you routinely re-image all craniopharyngioma patients during radiotherapy?
Yes, typically weekly. Ideally with MRI. HASTE MRI is often sufficient. If the cyst wall has enough calcifications and MRI authorization is a challenge, I will sometimes substitute a CT head (often as a re-sim using the treatment mask).
Should adjuvant radiation be given for an atypical (WHO II) meningioma of the thoracic spine after gross total resection?
Overall data are thin in this arena, in large part due to the relative scarcity of the disease. We recently published a bi-institutional experience (Wash U/U of Utah) of the largest cases series to date of 102 patients with spinal atypical meningioma (AM) underoing resection (Simpson I-IV) (Sun et a...
How would you manage a patient with surgically resected T3N1 NSCLC who is found to have one small brain metastasis on staging MRI?
For adjuvant chemotherapy, this is a difficult question for which there is no evidence-based answer, really. The "textbook" answer is that this is metastatic disease, and adjuvant therapy has only been proven for early stage disease. However, since there is still a reasonable chance of a cure after ...
Is there ever a situation where you would recommend radiation after gross total resection of a craniopharyngioma?
I favor observation.
How to you manage radiation brachial plexopathy in head & neck patients?
I am not aware of any effective therapy for brachial plexopathy. Bevacizumab has been reported to be beneficial in radiation-induced brain and retinal injury but I am not aware of its use in neuropathy. In any case, brachial plexopathy after RT of HN cancer is quite rare. I do not recall any BP case...
How long after WBRT would you wait to give SRS to a recurrent brain metastasis?
Practically speaking, radiation necrosis from whole brain radiation is very unusual. So most progression post whole brain radiation would be considered tumor recurrence and may be best treated with SRS. With newer immunotherapeutics, however, pseudoprogresion may be seen and needs to be considered. ...
What is your treatment approach for re-irradiation of a pituitary adenoma?
Re-irradiation for a pituitary adenoma is very challenging situation, since almost certainly would exceed normal tissue tolerance of optic apparatus. If re-irradiation is deemed necessary, stereotactic radiation either SRS or SRT should be used. Stereotactic RT only need minimum margin, usually 0-2...