Search

Purpose: Stereotactic radiosurgery (SRS) may be an alternative to anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). Visual field defects (VFD) occur in 9-100% of patients following open surgery for MTLE. Postoperative VFD after minimally invasive versus open surgery may differ.Methods: This prospective trial randomized patients with unilateral hippocampal sclerosis and concordant video-EEG findings to SRS versus ATL. Humphries perimetry was obtained at 24 m after surgery. VFD ratios (VFDR = proportion of missing homonymous hemifield with 0 = no VFD, 0.5 = complete superior quadrantanopsia) quantified VFD. Regressions of VFDR were evaluated against treatment arm and covariates. MRI evaluated effects of volume changes on VFDR. The relationships of VFDR with seizure remission and driving status 3 years after surgery were evaluated.Results: No patients reported visual changes or had abnormal bedside examinations, but 49 of 54 (91%) of patients experienced VFD on formal perimetry. Neither incidence nor severity of VFDR differed significantly by treatment arm. VFDR severity was not associated with seizure remission or driving status.Conclusion: The nature of VFD was consistent with lesions of the optic radiations. Effective surgery (defined by seizure remission) of the mesial temporal lobe results in about a 90% incidence of typical VFD regardless of method. [ABSTRACT FROM AUTHOR]

Background & Aims: Hepatocellular carcinoma (HCC) has limited treatment options; long-term outcomes following intra-arterial radiation are unknown. We assessed clinical outcomes of patients treated with intra-arterial yttrium-90 microspheres (Y90). Methods: Patients with HCC (n = 291) were treated with Y90 as part of a single-center, prospective, longitudinal cohort study. Toxicities were recorded using the Common Terminology Criteria version 3.0. Response rate and time to progression (TTP) were determined using World Health Organization (WHO) and European Association for the Study of the Liver (EASL) guidelines. Survival by stage was assessed. Univariate/multivariate analyses were performed. Results: A total of 526 treatments were administered (mean, 1.8; range, 1–5). Toxicities included fatigue (57%), pain (23%), and nausea/vomiting (20%); 19% exhibited grade 3/4 bilirubin toxicity. The 30-day mortality rate was 3%. Response rates were 42% and 57% based on WHO and EASL criteria, respectively. The overall TTP was 7.9 months (95% confidence interval, 6–10.3). Survival times differed between patients with Child–Pugh A and B disease (A, 17.2 months; B, 7.7 months; P = .002). Patients with Child–Pugh B disease who had portal vein thrombosis (PVT) survived 5.6 months (95% confidence interval, 4.5–6.7). Baseline age; sex; performance status; presence of portal hypertension; tumor distribution; levels of bilirubin, albumin, and α-fetoprotein; and WHO/EASL response rate predicted survival. Conclusions: Patients with Child–Pugh A disease, with or without PVT, benefited most from treatment. Patients with Child–Pugh B disease who had PVT had poor outcomes. TTP and overall survival varied by patient stage at baseline. These data can be used to design future Y90 trials and to describe Y90 as a potential treatment option for patients with HCC. [Copyright &y& Elsevier]

Purpose: To identify key prognostic clinical and imaging variables in patients undergoing yttrium-90 radioembolization (90Y) for liver malignancies. Materials and Methods: Patients with liver malignancies that progressed despite standard-of-care therapy were treated with 90Y from 2002 to 2006. Baseline functional status, laboratory values, and diagnostic imaging were assessed before therapy. Imaging follow-up was performed 1 month after treatment and subsequently at 3-month intervals. Patients were followed for survival from the time of their first 90Y treatment. Results: Patients with follow-up imaging after radioembolization (N = 130) were included in this analysis. Primary malignancies included colon, neuroendocrine, and others. The following clinical variables had a significant effect on survival on multivariate analysis: Eastern Cooperative Oncology Group (ECOG) performance status (PS) greater than 0 (hazard ratio [HR], 7.98; 95% CI, 3.98–16), hepatic tumor burden of 51%–75% (HR, 2.46; 95% CI, 1.01–6.02), bilirubin level greater than 1.3 mg/dL (HR, 2.60; 95% CI, 1.27–5.34), hepatic metastases from breast cancer (HR, 2.51; 95% CI, 1.13–5.61), response on imaging based on World Health Organization (WHO) criteria (HR, 0.48; 95% CI, 0.24–0.94), and lymphocyte depression (HR, 0.56; 95% CI, 0.31–0.96). Among patients with colorectal cancer metastases to the liver, the HR for survival on univariate analysis for responders compared with nonresponders (per WHO criteria) was 0.26 (95% CI, 0.10–0.69). Conclusions: Cancer-related symptoms (ie, ECOG PS > 0), hepatic tumor burden greater than 50%, increased bilirubin levels, and hepatic metastases from breast cancer were found to be negative prognostic factors. Tumor response to therapy and lymphocyte depression were associated with favorable prognosis. Additionally, WHO response was identified to be a favorable prognostic factor in patients with colorectal cancer metastases. These findings may be useful when counseling patients regarding prognosis of their hepatic disease. [Copyright &y& Elsevier]

Purpose: To present data from patients with breast cancer liver metastases who underwent radioembolization with yttrium (90Y) microspheres. Materials and Methods: Using standard 90Y lobar treatment protocol, 27 female patients with progressing liver metastases on standard of care polychemotherapy were treated under an open-label phase 2 protocol. After treatment, we assessed (a) tumor response using computed tomography and/or positron emission tomography, (b) biochemical toxicity, and (c) survival. Results: The mean age of the patients was 52. Seventeen (63%) patients received 20 left lobe treatments (median radiation dose, 123 Gy; mean, 119 Gy), and 20 (74%) patients received 22 right lobe treatments (median radiation dose, 121 Gy; mean, 109 Gy) to the treatment site. No significant dose-difference was noted between the two lobes (P = .69). Tumor response on 90-day follow-up computed tomography showed (a) complete and partial response in nine (39.1%) patients, (b) stable disease in 12 (52.1%) patients, and (c) progressive disease in 2 (8.8%) patients. Positive tumor response on positron emission tomography was noted in 17 (63%) patients. Three of 27 (11%) patients (Eastern Cooperation Oncology Group 1, 2, or 3) showed bilirubin toxicity of grade 3, all of which were attributed to disease progression. Median survival for Eastern Cooperation Oncology Group 0 versus 1, 2, or 3 patients was 6.8 months and 2.6 months, respectively (P = .24) and for patients with tumor burden <25% versus >25% was 9.4 and 2.0 months, respectively (P = .46). Conclusions: Radioembolization with 90Y brachytherapy device may be a viable therapeutic option for the treatment of breast cancer liver metastases in patients who have progressed or failed on standard of care polychemotherapy. [Copyright &y& Elsevier]

Abstract: The results of near-infrared Fourier transform Raman spectral examination of cement minerals, several commercial Portland cements, and hydrating Portland cements are critically examined. It is shown that structured fluorescent effects dominate the observed spectra for C3S, C2S, and cement, and none of the bands generated by this mode of examination is a true Raman band. The apparent bands for the Portland cements are in different positions to those for the individual cement minerals. The fluorescence-derived spectra for different cements are similar to each other but vary enormously in intensity for different cements. Hydration progressively reduces the intensity of the bands, but does not generate bands at new locations. It is tentatively suggested that the fluorescence effect may be somehow associated with the status of the cement components as orthosilicates (i.e., composed of isolated silica tetrahedra. Samples of high-purity C2S exhibit the fluorescence effect, but samples of CS (wollastonite) of similar purity do not. The latter are metasilicates (i.e., composed of linked chains of silica tetrahedra). They exhibit normal Raman Stokes and anti-Stokes bands. [Copyright &y& Elsevier]

We describe an 80-year-old woman with intraventricular silicone oil mimicking traumatic pathology upon presentation to the emergency department after a ground-level fall. Intraventricular migration of silicone oil from prior intraocular endotamponade is rare having only been described in a handful of case reports. While it has a unique and characteristic appearance on imaging, intraventricular silicone oil can be confused with intraventricular hemorrhage or calcified ventricular neoplasms. Recognition and differentiation of intraventricular silicone oil from more sinister pathology is essential for the radiologist, neurologist and neurosurgeon and can be done with routine head CT scan. We discuss the imaging findings of intraventricular silicone oil and review the current understanding of this unusual phenomenon. [ABSTRACT FROM AUTHOR]

Increasing tourism and population growth, exacerbated by migration, are placing pressure on the health and resilience of natural resources worldwide. This is evident in complex tropical coastal systems, particularly Small Island and Small Island Developing States (SIDS), where limited resources, fragile environments and climate change risk result in sustainable development challenges. The relationship between residents' perceived impacts of tourism, marine resource health, and support for future development was investigated through face-to-face semi-structured interviews with 57 stakeholders, including heads of households, fishers and those working in the tourism sector, on the Island of Grand Turk (Turks and Caicos Islands). Perceptions of the economic, social and environmental impact of tourism were not significantly associated with residents' socio-demographics. However, Turks and Caicos nationals were significantly more likely to support future tourism development than non-nationals. Residents that linked tourism with environmental degradation showed significantly reduced support for tourism development. Proposed developments which promote overnight tourism were viewed most positively by respondents highlighting a need for strategic growth of the tourism sector to consider income generation outside of the cruise terminal. Results highlight the need for more balanced consideration of the effects of tourism on socio-economic factors along with environmental considerations in communities highly depended on marine resources. Thus, context-specific understanding of residents' perceptions and how this might influence support for future development is vital to building policies that are reflective of local priorities. • Resident perceptions of tourism impact influence support for tourism development. • Perceptions of environmental decline reduce support for tourism development. • 50% of respondents perceived tourism to be the main cause of marine degradation. • Tourism can exacerbate community conflict leading to reduced social cohesion. • Policies should focus on overnight tourism and facilitating resident participation. [ABSTRACT FROM AUTHOR]

Background & Aims: Chemoembolization is one of several standards of care treatment for hepatocellular carcinoma (HCC). Radioembolization with Yttrium-90 microspheres is a novel, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC. Methods: We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up time points. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multivariate analyses were performed. Results: Abdominal pain and increased transaminase activity were more frequent following chemoembolization (P < .05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs 36%, respectively, P = .104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, respectively, P = .046), median survival times were not statistically different (20.5 months vs 17.4 months, respectively, P = .232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P = .42). Conclusions: Patients with HCC treated by chemoembolization or radioembolization with Yttrium-90 microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post hoc analyses of sample size indicated that a randomized study with > 1000 patients would be required to establish equivalence of survival times between patients treated with these two therapies. [Copyright &y& Elsevier]

Abstract: Background: Single suture craniosynostoses were long considered a benign condition with little risk of complications. In many cases, parents may forgo surgical correction because of the inherent risks of surgical intervention. Case Description: We report 2 cases of uncorrected sagittal synostosis associated with the development of Chiari malformations with syringomyelia later in life. To our knowledge, this is the first report of symptomatic Chiari malformations associated with uncorrected sagittal synostosis. We discuss mode of presentation and management in each case. We propose that these patients either have a pathophysiological predisposition to Chiari malformations based on the compensatory bone growth pattern in sagittal synostosis resulting in craniocephalic disproportion or that there may be an underlying genetic alteration accounting for the association of the 2 processes. Conclusions: Further investigations are warranted to investigate whether the incidence of Chiari malformations is decreased in patients who have undergone early correction of an isolated sagittal synostosis. We conclude that patients with sagittal synostosis should be evaluated for Chiari malformations before being discharged permanently from a neurosurgical practice. [Copyright &y& Elsevier]

A 51-year-old man with rheumatoid arthritis and diabetes mellitus presented with new onset left-sided hemiparesis, left-sided neglect, and left-sided incongruous, denser inferiorly, homonymous hemianopsia. Magnetic resonance image of the brain showed prominent swelling of the right frontal, parietal, and occipital lobes greater than on the left with significant change in the fluid-attenuated inversion recovery signal in the gray matter. Perinuclear antineutrophil cytoplasmic antibodies titers were elevated, and skin biopsy demonstrating leukocytoclastic vasculitis. He showed marked clinical and radiographic improvement in association with recovery of vascular abnormalities after the initiation of prednisone, pulse therapy with methylprednisolone, and methotrexate. Clinicians should be aware of the possibility of neuro-ophthalmic manifestations of rheumatoid arthritis, including rheumatoid arthritis–related vasculitis causing homonymous hemianopsia. [ABSTRACT FROM AUTHOR]

Purpose: Radiosensitizing chemotherapy improves the outcomes in comparison with radiation alone for gastrointestinal cancers. The delivery of radiation therapy with yttrium90 (90Y) radioembolization, in combination with the radiosensitizing chemotherapeutic agent capecitabine, provides the opportunity to enhance the effects of radiation on hepatic malignancies. This phase 1 study sought to determine the maximum tolerated dose (MTD) of 90Y plus capecitabine in patients with cholangiocarcinoma or liver metastases confined to the liver. Methods and Materials: Patients were given initial treatment at full-dose capecitabine during days 1 to 14 of a 21-day cycle. At days 1 to 7 of the second cycle, whole-liver 90Y was given at the test dose, after which time capecitabine was continued. Dose-limiting toxicity (DLT) was determined 6 weeks after 90Y infusion. If a DLT was not observed, the 90Y dose was escalated. The planned dose cohorts were 110, 130, 150, and 170 Gy. The primary endpoint was to determine the MTD of 90Y with full-dose capecitabine. Results: Sixteen patients were treated according to the study protocol. Two patients experienced DLTs. Nine patients required capecitabine dose reduction as a result of toxicities attributable to capecitabine alone. The criteria for establishing 90Y MTD were not met, indicating an MTD of >170 Gy. Conclusion: The MTD of 90Y delivered in conjunction with capecitabine in the setting of intrahepatic cholangiocarcinoma or metastatic disease confined to the liver exceeds 170 Gy. This is the highest 90Y dose reported to date and has important implications on combined therapy with the radiosensitizing oral chemotherapeutic capecitabine. Further studies are under way. [Copyright &y& Elsevier]

Purpose: To present long-term outcomes on the safety and efficacy of Yttrium-90 radioembolization in the treatment of unresectable hepatic neuroendocrine metastases refractory to standard-of-care therapy. Methods and Materials: This study was approved by our institutional review board and was compliant with the Health Insurance Portability and Accountability Act. Forty patients with hepatic neuroendocrine metastases were treated with 90Y radioembolization at a single center. Toxicity was assessed using National Cancer Institute Common Terminology Criteria v3.0. Response to therapy was assessed by World Health Organization (WHO) guidelines for size and European Association for the Study of the Liver disease (EASL) guidelines for necrosis. Time to response and overall survival were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed. Results: The median dose was 113 Gy (29–299 Gy). Clinical toxicities included fatigue (63%), nausea/vomiting (40%), abdominal pain (18%), fever (8%), diarrhea and weight loss (5%); Grade 3 and 4 bilirubin toxicities were experienced by 2 patients and 1 patient, respectively. Different responses were noted by WHO (complete response, 1.2%; partial response, 62.7%) and EASL (complete response, 20.5%; partial response, 43.4%). Median time to response was 4 and 4.9 months by lesion and patient, respectively. The 1-, 2-, and 3-year overall survival rates were 72.5%, 62.5%, and 45%, respectively. Eastern Cooperative Oncology Group (ECOG) performance score 0 (p < 0.0001), tumor burden ≤25% (p = 0.0019), albumin ≥3.5 g/dL (p = 0.017), and bilirubin ≤1.2 mg/dL (p = 0.002) prognosticated survival on univariate analysis; only ECOG performance score 0 and bilirubin ≤1.2 mg/dL prognosticated better survival outcome on multivariate analysis (p = 0.0001 and p = 0.02). Conclusion: Yttrium-90 therapy for hepatic neuroendocrine metastases leads to satisfactory tumor response and patient survival with low toxicity, in line with published national guidelines recommending radioembolization as a potential option for unresectable hepatic neuroendocrine metastases. [Copyright &y& Elsevier]

Objectives: To investigate the efficacy and toxicity of single-agent erlotinib in chemotherapy-naive castration-resistant prostate cancer. Methods: Eligible patients received erlotinib at 150 mg daily until disease progression. Toxicity was assessed every 2 weeks and responses every 8 weeks. Primary end point was assessing the overall clinical benefit measured as the sum of stable disease, partial response, and complete response. Secondary end points included time to disease progression, overall survival, and toxicity using the National Cancer Institute Common Toxicity Criteria version 3.0. Results: A total of 29 patients were enrolled in this study. Median age was 77 and median prostate-specific antigen was 66.3 ng/mL. Of 22 evaluable patients, 2 met the criteria for partial response and 5 demonstrated stable disease for an overall clinical benefit of 31%. PSA-doubling time improved in all responding patients to a median of 6 months from 3 months before entry into the study. One patient remained in study at 28 months, and 2 had > 50% decrease in their serum PSA level. Median time to disease progression was 2 months, but at 12 months, 9% of patients were progression-free. Median overall survival was 16.3 months, with 1- and 2-year survival rates of 58% and 27%, respectively. Erlotinib was well tolerated, with only 2 patients requiring dose reductions. Adverse events were as expected with grade 3 or 4 diarrhea, fatigue, and rash occurring in 10%, 6%, and 6% of patients, respectively. Conclusions: Erlotinib has moderate activity in chemotherapy-naive castration-resistant prostate cancer, with some patients showing biochemical response. Future studies investigating this agent in combination are warranted. (This trial was registered at http://NCI.gov, NCT00272038). [Copyright &y& Elsevier]