Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
What is the shortest interval you would consider to deliver re-irradiation for a recurrent glioblastoma?
Re-irradiation (assuming infield local progression) doesn't usually get discussed until more than 6 months following initial radiation therapy, likely because any increase before that is going to be possible pseudo progression. But after that point if there is increasing contrast enhancement suspici...
Would you recommend radiation therapy for a pathologic vertebral compression fracture already treated with kyphoplasty and RFA (OsteoCool)?
Assuming there is active disease in the vertebral body in question, I would recommend radiation therapy. An abstract was presented at the last ASTRO describing a retrospective small series from Roswell Park (Prezzano et al) suggesting that the combination of RFA and RT was beneficial for spine metas...
How do you manage grade III oligodendroglioma?
Given that these tumors predominantly occur in younger adults, and are often slowly progressive, there is an easy tendency to become complacent about the long-term behavior and outcomes with this disease. The bottom lines with this tumor are as follows: The diagnosis is complex, and often difficult,...
How do you manage recurrent atypical meningiomas in patients who have previously received radiotherapy?
This question, I fear, requires some underpinning. A recurrent atypical meningioma is an aggressive tumor, more so that than appears to be appreciated broadly. Even between first and second recurrence, as shown in a study by Bagshaw and colleagues at the University of Utah (Neurosurgery 126:1822–1...
For a recurrent medulloblastoma in the posterior fossa several years after initial standard risk therapy (23.4 Gy CSI), and in which the patient is still less than 18, how would you approach re-irradiation?
If the recurrences are localized to the resection bed, I would re-irradiate only the recurrences (and possibly the entire resection bed depending on number of recurrences). If there is evidence of CSF dissemination (recurrences not associated with primary--whether in posterior fossa or not) then CSI...
How would you approach treatment in a patient with Fanconi anemia and glioblastoma?
This is challenging due to the sensitivity of Fanconi anemia patients to DNA-damaging treatment. I would maximize resection if possible and then treat with radiation, since it is a mainstay of therapy, despite the risk. I would opt for proton radiation if possible to minimize exposure of normal tiss...
What is the best imaging study to differentiate between recurrent glioblastoma and pseudoprogression?
Chemo-radiation-induced pseudoprogression (Psp) and/or necrosis present with MRI findings indistinguishable from tumor recurrence on conventional contrast-enhanced MRI. However, while early progressive disease (ePD) indicates treatment failure and necessitates a change in therapy, Psp indicate succe...
Do you include the dural tail when treating benign meningioma with SRS?
Usually not; it is not common for the dural tail to be directly involved by tumor; however, in some cases, one can visualize tumor approaching the dural tail as distinct from the vascular dural tail, in which case the tumor of course needs to be targeted
Is it acceptable to treat glioblastoma with upfront SRS instead of fractionated external beam RT?
There is good prospective randomised data in this setting for using hypofractionated RT alone (34/10 fractions or 40/15 fractions) or Temodar alone (if MGMT methylated). If the goal is palliation and QOL improvement, either of the two based on the clinical situation is a viable option.There is no go...
What is the most appropriate adjuvant treatment for a gross totally resected recurrent spinal meningioma that has not received prior radiation?
Our CNS radonc group discussed options of therapy in this scenario at our faculty QA meeting. In general, it was acknowledge that options of management would be case specific, and could vary given the rarity of these cases and the limited number of published institutional series. Overall, our group ...