Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
How do you sequence TTFields into your salvage therapy plan for patients with recurrent glioblastoma?
For those patients who have not had TTF previously (we do not offer it in the salvage setting if they had received it initially), we evaluate for clinical trial eligibility first, and offer this option (unless for clinical reasons resection is urgently indicated). If a clinical trial is available, a...
Are there specific radiographic features that would alter your management of a presumed meningioma?
This question is particularly relevant for a patient who has a history of a cancer and a dural-based lesion that may represent metastasis or meningioma. Edema, as @Dr. First Last related, may suggest atypical histology. Necrosis may suggest a more malignant tumor, including malignant meningioma or d...
How do you manage a pediatric patient less than 3 years old with first relapse of medulloblastoma?
I am going to assume that this child was treated with high dose chemotherapy and no cranio-spinal irradiation prior to this progression since this is the most often used approach albeit not the only one. As all practicing pediatric Neuro-oncologists are aware, this age group is one of the most chall...
How do cytopenias factor into your decision of whether to hold radiotherapy during treatment of a glioblastoma?
Patients will sometimes need a chemo dose reduction or hold, but we typically do not stop RT, once started. In the case of severe cytopenia, I might hold RT on a case-by-case basis (e.g., platelets <10k despite holding temozolomide) and in discussion with the neuro-oncologist.
How do you manage a supratentorial anaplastic ependymoma in an adult?
Unfortunately, given the rarity of this tumor, we'll never know for sure. However, I do treat those patients similar to high grade gliomas in adults. Having said that, in high grade gliomas, I use smaller margins 0.5-1 cm (GTV --> CTV) and I think it would be appropriate in this setting as well. A b...
How soon after surgery do you start chemotherapy for extensive stage SCLC following resection of a brain metastasis?
I believe chemotherapy is the backbone of therapy for small cell lung cancer. If a patient has asymptomatic brain metastases, I start with chemotherapy (or chemoimmunotherapy) alone and follow with repeat brain imaging. I will treat with RT after initial 4 cycles of chemotherapy if brain disease is ...
How do you approach treatment of an IDH wild-type low-grade astrocytoma in an elderly patient?
Inherent in this good question are really two separate issues: 1) how to approach IDH-wt LGG and 2) how to treat glioma in the elderly (and/or frail).The first issue is addressed by the recent cIMPACT-NOW update #3 which states that in the presence of an IDH-wt gr 2-3 glioma, the presence of one of ...
What is your treatment approach to radiation-induced meningiomas?
There is an unambiguous relationship between ionizing radiation and meningioma, the most commonly reported radiation-associated neoplasm [1,2]. It is thus perhaps curious that radiation therapy (RT) is 1 of the only 2 definitive management options for meningioma in the current era. Systemic therapie...
In the treatment of recurrent trigeminal neuralgia, what local therapy would you recommend after failure of medical therapy?
I will recommend surgery (microvascular decompression) only when there is a surgically fixable abnormality, such as vascular compression. In that case, microvascular decompression is more effective than SRS. Otherwise, I will offer SRS, which can be offered twice targeting a root entry zone and a mo...
How would you manage the cavity of a resected anaplastic meningioma with pulmonary metastases?
Metastatic meningioma outside the CNS is rare, and its incidence has been estimated to be 0.1% with the lung being the most common site for distant metastases (Surov et al., PMID 23404622). There is no clear standard therapy for the management of metastatic meningioma. Suppose this was an anaplastic...