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Chinese Clinical Oncology Aug 2023Radiation is integral to the treatment of glioblastoma (GBM). However, radiation-induced scalp toxicity can negatively impact patients' quality of life. Volumetric...
BACKGROUND
Radiation is integral to the treatment of glioblastoma (GBM). However, radiation-induced scalp toxicity can negatively impact patients' quality of life. Volumetric modulated arc therapy (VMAT) optimizes the dose to organs at risk (OARs). We hypothesize that a scalp-sparing VMAT (SSV) approach can significantly reduce undesirable doses to the scalp without compromising the target dose.
METHODS
This is a retrospective cross-sectional study of GBM patients who originally received radiation with non-SSV. We contoured the scalp as a 5 mm rind-like structure beneath the skin above the level of the foramen magnum. We replanned our patients using SSV techniques. We compared dosimetric data for the scalp, planning target volume (PTV), and select critical normal structures between non-SSV and SSV plans.
RESULTS
Nineteen patients with newly diagnosed GBMs were included in our study. All patients received 60 Gy in 30 fractions. 9 patients received it in a single course. The rest received 46 Gy in 23 fractions to an initial volume followed by 14 Gy in 7 fractions to a cone-down volume (split course). New VMAT plans were generated after adding the scalp as an OAR. The median scalp volume was 416 cm3 (363-468 cm3). The median reductions in scalp Dmin, Dmax, and Dmean were 43.5% (-100% to 0%), 2.8% (+13.4% to -24.9%), and 15.7% (+2.1% to -39.9%) respectively. Median reductions in scalp D20cc and D30 cc were 19.5% (-2.7% to -54.5%), and 19.0% (-5.3% to -39.5%) respectively. The median volumes of the scalp receiving 30 Gy, 40 Gy, and 50 Gy were reduced by 42.3% (-70.6% to -12.5%), 72% (-100% to -2.3%), and 92.4% (-100% to +5.4%) respectively. There were no significant differences in the doses delivered to the PTV, brainstem, optic nerves, and optic chiasm between SSV and non-SSV plans.
CONCLUSIONS
SSV can significantly reduce scalp radiation dose without compromising target coverage or critical normal structure doses. This may translate into reduced acute and late radiation toxicity to the scalp. A prospective trial evaluating the clinical benefits of SSV is ongoing (NCT03251027).
Topics: Humans; Cross-Sectional Studies; Glioblastoma; Prospective Studies; Quality of Life; Radiation Dosage; Radiotherapy, Intensity-Modulated; Retrospective Studies; Scalp; Clinical Trials as Topic
PubMed: 37699601
DOI: 10.21037/cco-23-15 -
Journal of Neurosurgery. Case Lessons Jan 2024To date, only a few cases of sellar and suprasellar glioblastomas have been reported even though high-grade glioma constitutes the most common adult brain tumor,...
BACKGROUND
To date, only a few cases of sellar and suprasellar glioblastomas have been reported even though high-grade glioma constitutes the most common adult brain tumor, commonly arising in the cerebral hemispheres. It arises de novo from astrocytes within the optic nerve, optic chiasm, or optic tracts and is quite challenging to diagnose and treat. To the authors' knowledge, there are 72 cases (including this one) of optic glioma malignancies in the medical literature, 30 corresponding to glioblastomas.
OBSERVATIONS
The authors present the diagnostic considerations and challenges, management strategies, and clinical course of a very large sellar-suprasellar glioblastoma in a 19-year-female who had never received radiation therapy or prior surgery.
LESSONS
Sellar-suprasellar glioblastomas, although extremely rare, are known to occur and pose challenges in their diagnosis and preoperative treatment planning. The presence of diffusion restriction on diffusion-weighted magnetic resonance imaging in a mass lesion that has ring and nodular postcontrast enhancement in addition to absent calcification on computed tomography should be alert to the possibility of a high-grade mass. This is extremely important for preoperative patient counseling and planning for the multimodal treatments, because sellar-suprasellar glioblastomas carry a poorer prognosis than the common benign mass lesions in the region.
PubMed: 38224589
DOI: 10.3171/CASE23565 -
Annals of Palliative Medicine Mar 2024Because of improved survival of cancer patients, more patients irradiated for brain metastases develop intracerebral recurrences requiring subsequent courses of...
Because of improved survival of cancer patients, more patients irradiated for brain metastases develop intracerebral recurrences requiring subsequent courses of radiotherapy. Five studies focused on reirradiation with whole-brain radiation therapy (WBRT) after initial WBRT for brain metastases. Following the second WBRT course, improvement of clinical symptoms was found in 31-68% of patients. Rates of neurotoxicity, such as encephalopathy or cognitive decline, were reported in two studies (1.4% and 32%). In another study, severe or unexpected adverse events were not observed. Survival following the second WBRT course was generally poor, with median survival times of 2.9-4.1 months. The survival prognosis of patients receiving two courses of WBRT can be estimated by a scoring tool considering five prognostic factors. Three studies investigated reirradiation with single-fraction stereotactic radiosurgery (SF-SRS) following primary WBRT. One-year local control rates were 74-91%, and median survival times ranged between 7.8 and 14 months. Rates of radiation necrosis (RN) after reirradiation were 0-6%. Seven studies were considered that investigated re-treatment with SF-SRS or fractionated stereotactic radiation therapy (FSRT) following initial SF-SRS or FSRT. One-year local control rates were 60-88%, and the median survival times ranged between 8.3 and 25 months. During follow-up after reirradiation, rates of overall (asymptomatic or symptomatic) RN ranged between 12.5% and 30.4%. Symptomatic RN occurred in 4.3% to 23.9% of cases (patients or lesions). The risk of RN associated with symptoms and/or requiring surgery or corticosteroids appears lower after reirradiation with FSRT when compared to SF-SRS. Other potential risk factors of RN include the volume of overlap of normal tissue receiving 12 Gy at the first course and 18 Gy at the second course of SF-SRS, maximum doses ≥40 Gy of the first or the second SF-SRS courses, V12 Gy >9 cm3 of the second course, initial treatment with SF-SRS, volume of normal brain receiving 5 Gy during reirradiation with FSRT, and systemic treatment. Cumulative EQD2 ≤100-120 Gy2 to brain, <100 Gy2 to brainstem, and <75 Gy2 to chiasm and optic nerves may be considered safe. Since most studies were retrospective in nature, prospective trials are required to better define safety and efficacy of reirradiation for recurrent or progressive brain metastases.
PubMed: 38509654
DOI: 10.21037/apm-23-593 -
Development (Cambridge, England) Jan 2024Binocular vision requires the segregation of retinal ganglion cell (RGC) axons extending from the retina into the ipsilateral and contralateral optic tracts. RGC axon...
Binocular vision requires the segregation of retinal ganglion cell (RGC) axons extending from the retina into the ipsilateral and contralateral optic tracts. RGC axon segregation occurs at the optic chiasm, which forms at the ventral diencephalon midline. Using expression analyses, retinal explants and genetically modified mice, we demonstrate that CXCL12 (SDF1) is required for axon segregation at the optic chiasm. CXCL12 is expressed by the meninges bordering the optic pathway, and CXCR4 by both ipsilaterally and contralaterally projecting RGCs. CXCL12 or ventral diencephalon meninges potently promoted axon outgrowth from both ipsilaterally and contralaterally projecting RGCs. Further, a higher proportion of axons projected ipsilaterally in mice lacking CXCL12 or its receptor CXCR4 compared with wild-type mice as a result of misrouting of presumptive contralaterally specified RGC axons. Although RGCs also expressed the alternative CXCL12 receptor ACKR3, the optic chiasm developed normally in mice lacking ACKR3. Our data support a model whereby meningeal-derived CXCL12 helps drive axon growth from CXCR4-expressing RGCs towards the diencephalon midline, enabling contralateral axon growth. These findings further our understanding of the molecular and cellular mechanisms controlling optic pathway development.
Topics: Animals; Mice; Axons; Diencephalon; Optic Chiasm; Retina; Retinal Ganglion Cells; Visual Pathways
PubMed: 38095299
DOI: 10.1242/dev.202446 -
Journal of Neurosurgery. Case Lessons Aug 2023A glomus vagale tumor is an infrequent paraganglioma primarily characterized by auditory symptoms, cranial nerve involvement, or autonomic symptoms. However, visual...
BACKGROUND
A glomus vagale tumor is an infrequent paraganglioma primarily characterized by auditory symptoms, cranial nerve involvement, or autonomic symptoms. However, visual involvement is not commonly observed, and to date, no cases have been reported in the literature.
OBSERVATIONS
The case involves a 62-year-old female patient with a history of right carotid body tumor resection. She presented to the emergency department with a sudden decrease in visual acuity and bitemporal hemianopsia, accompanied by a left parietal headache. Initial brain magnetic resonance imaging (MRI) revealed a pituitary macroadenoma, which was completely resected. However, postoperatively, the patient developed left amaurosis. Subsequent brain MRI showed the presence of hemostatic material mixed with blood in the sellar region, causing displacement of the optic chiasm. A repeat intervention was performed, identifying bleeding from both cavernous sinuses. Head and neck angiography demonstrated a right glomus vagale tumor with abundant blood drainage into the right cavernous sinus. Embolization of the glomus vagale tumor was performed, resulting in no further bleeding and improvement of symptoms.
LESSONS
The aim of this case report is to describe a rare occurrence of bilateral visual disturbances caused by bleeding in both cavernous sinuses due to venous hypertension caused by a right glomus vagale tumor.
PubMed: 37581586
DOI: 10.3171/CASE23145 -
Cureus Aug 2023Non-functioning pituitary adenomas (NFPAs) are rare in females of reproductive age. We present the case of a 37-year-old pregnant woman in her second trimester with a...
Non-functioning pituitary adenomas (NFPAs) are rare in females of reproductive age. We present the case of a 37-year-old pregnant woman in her second trimester with a diagnosis of symptomatic pituitary macroadenoma with twin pregnancy. Magnetic resonance imaging (MRI) confirmed a well-defined macroadenoma compressing the optic chiasm, thus necessitating surgery. The patient underwent transnasal transsphenoidal resection of the tumor under general anesthesia. Anesthesia management posed challenges due to concurrent considerations of pregnancy and neurosurgery. Induction, maintenance, monitoring, and fluid management were carefully performed. The patient experienced a transient decrease in oxygen saturation, which improved with lung recruitment maneuvers. The surgery was successful without any complications. Postoperatively, an ophthalmology consultation was done, which showed an improvement in the patient's vision, as evidenced by the perimetry findings. Later, she delivered healthy twins at 36 weeks and six days of gestation. This case highlights the importance of a multidisciplinary approach and meticulous anesthetic management when dealing with pregnant patients undergoing non-obstetric surgery, ensuring optimal maternal-fetal perfusion and minimizing risks to both the mother and the fetus.
PubMed: 37664278
DOI: 10.7759/cureus.42891 -
Cureus Dec 2023A pituitary adenoma is an insidious and slow-growing neoplasm of the pituitary gland. No definitive aggravating factors have currently been reported for pituitary...
A pituitary adenoma is an insidious and slow-growing neoplasm of the pituitary gland. No definitive aggravating factors have currently been reported for pituitary adenoma enlargement. Our case demonstrates that the coronavirus disease 2019 (COVID-19) vaccine may be one of the risk factors aggravating tumor expansion. A 60-year-old woman experienced visual loss in her left eye for three days. Eight days before presentation or five days before visual loss, she received the fourth dose of the COVID-19 vaccine. The visual field showed bitemporal superior quadrantanopic scotoma, prominent on the left side. Neuroimaging revealed pituitary macroadenoma with a compressive effect on the optic chiasm. After diagnosis, endocrine work-up and tumor removal were successfully performed. Her vision and perimetry significantly improved. The COVID-19 vaccine is a candidate factor that might exacerbate pituitary gland enlargement. Additional data are essential to validate and establish the connection between the vaccine and this potential effect.
PubMed: 38229808
DOI: 10.7759/cureus.50685 -
Ophthalmology and Therapy May 2024This is a unique case report in medical literature for its detailing of diagnostics of an uncommon presentation of a rapid unexplained bilateral vision loss of a...
INTRODUCTION
This is a unique case report in medical literature for its detailing of diagnostics of an uncommon presentation of a rapid unexplained bilateral vision loss of a 73-year-old male diabetic patient. This report highlights the crucial role of advanced molecular diagnostics in difficult neurological cases and also elucidates the difficulties involved in diagnosing optic nerve glioblastoma, an exceptionally rare and aggressive tumour.
MAIN CONCERNS AND CLINICAL FINDINGS OF THE PATIENT
Slow and progressive loss of vision over 2 months, ultimately developing almost complete visual impairment in both eyes and a defect of right eye field of vision conclusively highlighted that the likely etiology was neuro-ophthalmic. Initially, the conditions were suspected to be an extended spectrum of diabetic eye disease complications but further deterioration was a hint towards something more substantive.
PRIMARY DIAGNOSES, INTERVENTIONS AND OUTCOMES
This entailed in-depth diagnosis processes that included an MRI and the analysis of cerebrospinal fluid. The important discovery was through stereotactic biopsies of the optic nerve revealing a high-grade glial neoplasm. Next generation sequencing confirmed the pathology as IDH-wildtype glioblastoma. Despite management, his vision continued to deteriorate. Hence, an aggressive clinical course was followed.
CONCLUSION
This case highlights the important learning need in considering glioblastoma of the optic chiasm as part of the differential diagnosis of rapid vision loss, which may present as multifocal brain lesions, especially in cases of rapid loss of vision where initial workup is negative. Quite a useful lesson that can be drawn from this case relates to the diagnostic process with advanced molecular profiling, more attention given to clinical suspicion and cutting-edge diagnostic tools applied in atypical presentation of neurological conditions.
PubMed: 38498279
DOI: 10.1007/s40123-024-00922-1 -
Radiology Case Reports Sep 2023Septo-optic dysplasia (SOD) is a rare malformation defined by septum pellucidum abnormalities and hypoplasia of the optic nerves and chiasm. It can be associated with...
Septo-optic dysplasia (SOD) is a rare malformation defined by septum pellucidum abnormalities and hypoplasia of the optic nerves and chiasm. It can be associated with cortical development malformations such as schizencephaly, which is then called septo-optic dysplasia plus. It usually manifests at birth, although it may not be diagnosed until childhood, or rarely, adolescence. We report the case of a 23 years old patient, with a history of epilepsy since early childhood never labeled, which was diagnosed with SOD-PLUS with brain MRI in our department.
PubMed: 37441455
DOI: 10.1016/j.radcr.2023.05.057 -
Ophthalmology and Therapy Jul 2024This study investigates how surgery for pituitary adenoma (PA) affects the visual pathway, examining changes in the retina, blood vessel density, and nerve function....
INTRODUCTION
This study investigates how surgery for pituitary adenoma (PA) affects the visual pathway, examining changes in the retina, blood vessel density, and nerve function. Since PAs often impair vision as a result of their location near visual structures, this research is key to understanding and improving vision recovery after surgery.
METHODS
Our study is based on a retrospective analysis of the historical data of 28 patients diagnosed with pituitary adenomas. We conducted assessments by reviewing preoperative and postoperative imaging records. These included optical coherence tomography (OCT) for retinal structure analysis, diffusion tensor imaging (DTI) for neural transmission evaluation, and optical coherence tomography angiography for assessing blood vessel density. These tools allowed for a detailed understanding of the structural and functional changes within the visual pathway following PA surgery.
RESULTS
OCT findings show postoperative changes in the eye: thinning in average and nasal circumpapillary retinal nerve fiber layer, thickening in macular central 1 mm inner plexus layer, ganglion cell complex, and nasal retinal nerve fiber layer. DTI reveals increased fractional anisotropy (FA) in the left optic chiasm and posterior optic nerve, decreased mid-segment optic nerve FA, and increased apparent diffusion coefficient (ADC) in the right optic chiasm and nerve segments. Early postoperative reduction in radial peripapillary capillaries plexus density is noted. Preoperative ganglion cell layer (GCL) thickness correlates with postoperative visual radiation FA and ADC values, especially in the inferior quadrant. A negative correlation exists between preoperative GCL thickness and postoperative visual field mean defect values, particularly on the temporal side and superior inner ring. All changes are statistically significant (P < 0.05).
CONCLUSIONS
The study finds that surgery for PA has varied effects on vision. Early post surgery, there are changes in the retina and nerve signals. Macular GCL thickness before surgery might predict early visual recovery, influencing future research and treatment for vision issues related to PA.
PubMed: 38822193
DOI: 10.1007/s40123-024-00966-3