Neurosurgery
Physician insights on operative techniques, spinal disorders, neuro-oncology, cerebrovascular disease, and functional neurosurgery.
Recent Discussions
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?
The EF14 trial included newly diagnosed glioblastoma patients who had gross total resections and those who had biopsies. Only 54% of patients had a GTR and 13% had biopsy. TTF plus temzolomide was associated with an increase in PFS and OS in all subgroups including extent of resection. So even if gr...
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...
How much volume reduction do you typically observe following radiotherapy for a meningioma?
Assuming this is for indolent grade I meningiomas, retrospective studies show that the range for volume reduction following fractionated radiotherapy or stereotactic radiosurgery can be anywhere from 13% to 61%. Also, the interval time to volume reduction may be anywhere from 6 months to years. In s...
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...