Non small cell lung cancer intracranial metastases radiosurgery

Non small cell lung cancer intracranial metastases radiosurgery

Multisession radiosurgery (M-GKS) may be an effective alternative for large brain metastases from Non small cell lung cancer (NSCLC). Specifically, severe radiation induced toxicity (≥ grade 3) did not occur in M-GKS for large-volume metastases. Although the long-term effects and results from larger samples remain unclear, M-GKS may be a suitable palliative treatment for preserving neurological function 1).

Traditionally, whole brain radiotherapy (WBRT) has been the cornerstone of Non small cell lung cancer intracranial metastases treatment, but its indication is a matter of debate. A randomized trial has shown that for patients with a poor prognosis, WBRT does not add quality of life (QoL) nor survival over the best supportive care. In recent decades, stereotactic radiosurgery (SRS) has become an attractive non-invasive treatment for patients with BM. Only the BM is irradiated to an ablative dose, sparing healthy brain tissue. Intracranial recurrence rates decrease when WBRT is administered following SRS or resection but does not improve overall survival and comes at the expense of neurocognitive function and QoL. The downside of SRS compared with WBRT is a risk of radionecrosis (RN) and a higher risk of developing new BM during follow-up. Currently, SRS is an established treatment for patients with a maximum of four BM. Several promising strategies are currently being investigated to further improve the indication and outcome of SRS for patients with BM: the effectivity and safety of SRS in patients with more than four BM, combining SRS with systemic therapy such as targeted agents or immunotherapy, shared decision-making with SRS as a treatment option, and individualized isotoxic dose prescription to mitigate the risk of RN and further enhance local control probability of SRS.

The review of Hartgerink et al., discusses the current indications of SRS and future directions of treatment for patients with BM of NSCLC with focus on the value of SRS 2).


Radiosurgery for multiple BMs is controversial, yet patients with EGFR Non small cell lung cancer intracranial metastases and Anaplastic lymphoma kinase non small cell lung cancer may be uniquely suited to benefit from this approach. These results support single and multiple courses of radiosurgery without WBRT for patients with oncogene-addicted NSCLC with four or more BMs 3).

References

1)

Park K, Kim JW, Chung HT, Paek SH, Kim DG. Single-Session versus Multisession Gamma Knife Radiosurgery for Large Brain Metastases from Non-Small Cell Lung Cancer: A Retrospective Analysis. Stereotact Funct Neurosurg. 2019 May 22:1-7. doi: 10.1159/000496154. [Epub ahead of print] PubMed PMID: 31117101.
2)

Hartgerink D, van der Heijden B, De Ruysscher D, Postma A, Ackermans L, Hoeben A, Anten M, Lambin P, Terhaag K, Jochems A, Dekker A, Schoenmaekers J, Hendriks L, Zindler J. Stereotactic Radiosurgery in the Management of Patients With Brain Metastases of Non-Small Cell Lung Cancer: Indications, Decision Tools and Future Directions. Front Oncol. 2018 May 9;8:154. doi: 10.3389/fonc.2018.00154. eCollection 2018. Review. PubMed PMID: 29868476; PubMed Central PMCID: PMC5954030.
3)

Robin TP, Camidge DR, Stuhr K, Nath SK, Breeze RE, Pacheco JM, Liu AK, Gaspar LE, Purcell WT, Doebele RC, Kavanagh BD, Rusthoven CG. Excellent Outcomes with Radiosurgery for Multiple Brain Metastases in ALK and EGFR Driven Non-Small Cell Lung Cancer. J Thorac Oncol. 2018 May;13(5):715-720. doi: 10.1016/j.jtho.2017.12.006. Epub 2017 Dec 19. PubMed PMID: 29269007.

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

The Scandinavian Neurotrauma Committee (SNC) published practical, evidence based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI).

1).


A prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 to November 2016. All consecutive adult patients with HI presenting to the ED within 24 hours from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients and the result was available at the ED. Head CTs were performed according to the on-call physician’s evaluation. Only the samples collected within 6 hours after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age=67.0 years, range=18-100; women=48.8%) were enrolled. Of those, 196 (66.4%) were scanned. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% CI=0.77-0.99) and specificity 0.19 (95% CI=0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI=0.12-0.25) and 0.94 (95% CI=0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED and 2 patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions following HI and have the potential to reduce unnecessary CT scanning 2).


In a large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, they compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.

The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.

The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI 3).

References

1)

Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760-6. PubMed PMID: 10780615.
2)

Minkkinen M, Iverson GL, Kotilainen AK, Pauniaho SL, Mattila V, Lehtimäki T, Berghem K, Posti JP, Luoto TM. Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults. J Neurotrauma. 2019 May 21. doi: 10.1089/neu.2018.6351. [Epub ahead of print] PubMed PMID: 31111795.
3)

Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med. 2018 Oct 12;16(1):176. doi: 10.1186/s12916-018-1166-8. PubMed PMID: 30309392; PubMed Central PMCID: PMC6182797.

Pediatric neurosurgery

Pediatric neurosurgery

Books

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Journals

Child’s Nervous System http://link.springer.com/journal/381

Journal of Pediatric Neurosciences http://www.pediatricneurosciences.com/

JOURNAL OF NEUROSURGERY:PEDIATRICS http://thejns.org

NEUROPEDIATRICS https://www.thieme-connect.com/products/ejournals/journal/10.1055/s-00000041

Pediatric neurosurgery journal

Regional comparison demonstrated a preference for the Journal of Neurosurgery and Child’s Nervous System, respectively, but four of the top five journals were common to both groups. Applying the verbal formulation of Bradford’s law to the North American citation database, a pattern of citation density was identified across the first three zones. Journals residing in the most highly cited first zone are presented as the core journals.

Bradford’s law can be applied to identify the core journals of neurosurgical subspecialties. While regional differences exist between the most highly cited and most frequently published in journals among North American and European pediatric neurosurgeons, there is commonality between the top five core journals in both groups 1).

Societies

International Bureau for Epilepsy

International League Against Epilepsy

Pediatric Neurosurgery Chapter of the Latinamerican Federation of Neurosurgical Societies (FLANC)

Resources

Hydrocephalus Association

About Kids Health Brain Tumours

Association for Spina Bifida and Hydrocephalus

Brain Tumour Research Assistance and Information Network

Hydrocephalus Foundation

Hydro Kids

International Bureau for Epilepsy

International League Against Epilepsy

The purpose of a study was to identify the national trends of exposure to pediatric procedures during neurosurgical residency and to subsequently evaluate how neurosurgery residents’ experiences correlate with the minimum requirements set forth by the American College of Graduate Medical Education (ACGME).

ACGME resident case logs from residents graduating between 2013 and 2017 were retrospectively reviewed. These reports were analyzed to determine trends in resident operative experience in pediatric procedures. The number of cases performed by residents was compared to the required minimums set by the ACGME within each pediatric surgical category. A linear regression analysis and t tests were utilized to analyze the change in cases performed over the study period.

A mean of 98.8 procedures were performed for each of the 877 residents graduating between 2013 and 2017. The total number of pediatric procedures declined at a rate of 1.7 cases/year (r2 = 0.77, p = 0.05). Spine and cerebrospinal fluid diversion procedures showed decreasing trends at rates of 1.9 (r2 = 0.70, p = 0.08) and 1.2 (r2 = 0.70, p = 0.08) cases/year, respectively. The number of trauma and brain tumor cases were shown to have increasing rates at 1.0 (r2 = 0.86, p = 0.02) and 0.3 (r2 = 0.69, p = 0.08) cases/year, respectively, with trauma cases showing significant increases. There was also a trend of increasing cases logged as the lead resident surgeon by 12.9 cases/year (r2 = 0.99, p < 0.001). The number of cases performed by the average graduating resident was also significantly higher than the minimums required by the ACGME; residents, on average, performed 3 times the required minimum number of pediatric cases.

Neurosurgical residents graduating from 2013 to 2017 reported significantly higher volumes of pediatric neurosurgery cases than the standards set for by the ACGME. During this time, there was also a significant trend of increasing cases logged as the lead resident surgeon, suggesting more involvement in the critical portions of pediatric cases. There was also a significant, but not clinically impactful, decrease in pediatric case volumes during this time. However, the overall data indicate that residents are continuing to gain valuable pediatric experience during residency training 2).

Perceived benefits and barriers to a career in pediatric neurosurgery: a survey of neurosurgical residents

Research suggests that there may be a growing disparity between the supply of and demand for both pediatric specialists and neurosurgeons. Whether pediatric neurosurgeons are facing such a disparity is disputable, but interest in pediatric neurosurgery (PNS) has waxed and waned as evidenced by the number of applicants for PNS fellowships. The authors undertook a survey to analyze current neurosurgical residents’ perceptions of both benefits and deterrents to a pediatric neurosurgical career. METHODS: All residents and PNS fellows in the United States and Canada during the academic year 2008-2009 were invited to complete a Web-based survey that assessed 1) demographic and educational information about residents and their residency training, particularly as it related to training in PNS; 2) residents’ exposure to mentoring opportunities from pediatric neurosurgical faculty and their plans for the future; and 3) residents’ perceptions about how likely 40 various factors were to influence their decision about whether to pursue a PNS career. RESULTS: Four hundred ninety-six responses were obtained: 89% of the respondents were male, 63% were married, 75% were in at least their 3rd year of postgraduate training, 61% trained in a children’s hospital and 29% in a children’s “hospital within a hospital,” and 72% were in programs having one or more dedicated PNS faculty members. The residencies of 56% of respondents offered 6-11 months of PNS training and nearly three-quarters of respondents had completed 2 months of PNS training. During medical school, 92% had been exposed to neurosurgery and 45% to PNS during a clinical rotation, but only 7% identified a PNS mentor. Nearly half (43%) are considering a PNS career, and of these, 61% are definitely or probably considering post-residency fellowship. On the other hand, 68% would prefer an enfolded fellowship during residency. Perceived strengths of PNS included working with children, developing lasting relationships, wider variety of operations, fast healing and lack of comorbidities, and altruism. Perceived significant deterrents included shunts, lower reimbursement, cross-coverage issues, higher malpractice premiums and greater legal exposure, and working with parents and pediatric health professionals. The intrinsic nature of PNS was listed as the most significant deterrent (46%) followed by financial concerns (25%), additional training (12%), longer work hours (12%), and medicolegal issues (4%). The majority felt that fellowship training and PNS certification should be recommended for surgeons treating of all but traumatic brain injuries and Chiari I malformations and performing simple shunt-related procedures, although they felt that these credentials should be required only for treating complex craniosynostosis. CONCLUSIONS: The nature of PNS is the most significant barrier to attracting residents, although reimbursement, cross-coverage, and legal issues are also important to residents. The authors provide several recommendations that might enhance resident perceptions of PNS and attract trainees to the specialty 3).


Central nervous system tumors account for the highest mortality among pediatric malignancies.

1)

Venable GT, Shepherd BA, Roberts ML, Taylor DR, Khan NR, Klimo P Jr. An application of Bradford’s law: identification of the core journals of pediatric neurosurgery and a regional comparison of citation density. Childs Nerv Syst.2014 Aug 7. [Epub ahead of print] PubMed PMID: 25098356.
2)

White MD, Zollman J, McDowell MM, Agarwal N, Abel TJ, Hamilton DK. Neurosurgical Resident Exposure to Pediatric Neurosurgery: An Analysis of Resident Case Logs. Pediatr Neurosurg. 2019 May 21:1-7. doi: 10.1159/000500299. [Epub ahead of print] PubMed PMID: 31112956.
3)

Dias MS, Sussman JS, Durham S, Iantosca MR. Perceived benefits and barriers to a career in pediatric neurosurgery: a survey of neurosurgical residents. J Neurosurg Pediatr. 2013 Nov;12(5):422-33. doi: 10.3171/2013.7.PEDS12597. Epub 2013 Aug 30. PubMed PMID: 23992238.
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