Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is your preferred treatment for spinal drop metastases from a glioblastoma?
This is a relatively uncommon, but challenging clinical situation, and usually the prognosis is poor. Our approach is as follows: 1. Detailed MR imaging of the spine to ensure that the failure is truly focal, and not multifocal or leptomeningeal: 2. Thorough re-imaging of the brain to ensure that t...
What margins do you use for glioblastoma in close proximity to critical structures?
Assuming standard fractionation to 60 Gy with concurrent temozolomide, I am struggling to think of a GBM patient who has had a complication due to radiation to adjacent critical structures. Since my GBM margins are not very large (Initial: 1 cm around the T2 + cavity. Cone-down: 1 cm around the cont...
What is your approach to a patient with a glioblastoma who cannot have an MRI?
We used contrast enhanced CT. Surveillance was done with the same. We were able to provide both post operative adjuvant RT and also stereotactic radiotherapy after localized recurrence. The PTV volume was postoperative cavity and contrast enhancement with 2 cm for adjuvant (single phase) and area of...
How do you manage cavernous sinus meningiomas?
Radiotherapy or radiosurgery depending on optic nerve dose
What are your indications for radiotherapy in children with pleomorphic xanthoastrocytoma?
Pleomorphic Xanthoastrocytoma is unique among other pediatric low grade gliomas in that it there is a high frequency of targetable alterations including BRAF V600E alterations and that there appears to be an increased risk of transformation relative to other pediatric low grade glioma histologies (P...
How would you approach primary CNS lymphoma in an elderly patient over 80 years old?
Patients >70-75 are poorly represented in trials and retrospective studies, and are in need of novel therapies with minimal toxicity. We know that radiation therapy is associated with increased neurocognitive morbidity in patients >60, but is often the only feasible approach if chemotherapy cannot b...
How would you manage a resected meningioma found to harbor a small focus of metastatic disease from a non-CNS primary malignancy?
Mets to a tumor (Collision) are seen, though rare. Simple answer: 1. Meningioma resection (Grade 1) or for that matter up to Grade II, irrelevant since the time to progression in a less than a Simpson Grade I resection would far outrun the metastatic cancer. 2. Treat the resection cavity like a met ...
Are there particular subgroups of patients with glioblastoma who derive the most benefit from TTFields?
No validated subgroup has been identified. Patients with MGMT methylated tumors appear to gain most from treatment, but the EF-14 study was not powered to answer that question and patients with unmethylated tumors still saw a benefit. I recommend TTfields to all patients with newly diagnosed gliobla...
What is the role for TTFields in patients who cannot undergo complete surgical resection for glioblastoma?
A gross total resection is not a requirement for the use of TTF, and therefore these patients can be evaluated for this therapeutic option.
What is your surveillance imaging schedule following treatment of a pituitary adenoma?
Pituitary adenomas usually change little in size after either fractionated RT or SRS, and they progress slowly. Therefore, yearly imaging to look for increase in size is sufficient. For secretory pituitary adenomas, periodic (every 3 to 6 months) measurement of the level of the hyper secreted hormon...