- Stereotactic radiosurgery (SRS) uses focused radiation to treat brain tumors and metastases. Common indications include brain metastases, where SRS alone may be sufficient for 1-3 lesions.
- Randomized trials have shown SRS alone leads to less cognitive decline than SRS plus whole brain radiation for limited brain metastases. However, SRS alone is associated with higher local recurrence rates.
- For resected brain metastases, observation or postoperative SRS may be appropriate depending on factors like number/size of lesions and extracranial disease control. Whole brain radiation provides improved intracranial control but not overall survival.
- For high grade gliomas, maximum safe resection followed by chemor
LUNG WITH BRAIN METASTASIS- DR UPASNA.pptxUpasna Saxena
Use of molecular GPA for deciding management of brain metastasis from lung cancer. approach to asymptomatic and symptomatic patients. criteria to help personalisation of treatment
LUNG WITH BRAIN METASTASIS- DR UPASNA.pptxUpasna Saxena
Use of molecular GPA for deciding management of brain metastasis from lung cancer. approach to asymptomatic and symptomatic patients. criteria to help personalisation of treatment
Protocol Presentation of study on Primary CNS lymphomaNarayan Adhikari
Study to evaluate the feasibility of response adapted whole brain radiotherapy after high dose methotrexate based chemotherapy in patients of newly diagnosed primary central nervous system lymphoma
Treatment of Brain Metastases Using the Current Predictive Models: Is the Pro...CrimsonpublishersCancer
Brain metastases from solid tumours are the most common intracranial tumours [1] and it occur in 40% of patients with cancer [2]. The most common primary tumours that metastasize to the brain are lung(40%),breast (25%) and melanoma (20%) [3]. The incidence is expected to be on the increase, due to improved survival, with use of modern cytotoxic drugs, targeted therapy, immunotherapy and modern radiotherapy techniques, in addition to greater use of magnetic resonance imaging of the brain. Brain metastases are common in the elderly, defined as above 60 years [4], and the interval between diagnosis of the primary and the development of brain metastases is variable, however some reported an average of 19 months [5] and adenocarcinoma is the commonest histology that metastasizes to the brain [6].
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Brain metastases from solid tumours are the most common intracranial tumours [1] and it occur in 40% of patients with cancer [2]. The most common primary tumours that metastasize to the brain are lung(40%),breast (25%) and melanoma (20%) [3]. The incidence is expected to be on the increase, due to improved survival, with use of modern cytotoxic drugs, targeted therapy, immunotherapy and modern radiotherapy techniques, in addition to greater use of magnetic resonance imaging of the brain. Brain metastases are common in the elderly, defined as above 60 years [4], and the interval between diagnosis of the primary and the development of brain metastases is variable, however some reported an average of 19 months [5] and adenocarcinoma is the commonest histology that metastasizes to the brain [6].
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
3. Common Indications for Radiosurgery or
Hypofractionated Stereotactic Radiotherapy
Perez & Brady's Principles and Practice of Radiation Oncology, 7th edition
4. Brain metastases
•Most common intracranial tumors in adults
•Estimated 10–40% of cancer patients develop
metastases during course of illness
•Most common in patients with lung, breast,
melanoma, renal cell, & gastrointestinal carcinoma
•Historically, whole brain radiation therapy (WBRT):
Standard of care
5. Brain metastases
•Improved extracranial control and prognosis due to
development of better systemic therapies & surgical
techniques
•Optimizing intracranial control while minimizing
late neurotoxicity important
6. Estimating Prognosis of Patients with Brain
Metastasis
Recursive partitioning analysis (RPA)
• Radiation Therapy Oncology Group’s (RTOG’s) RPA first
published in 1997
• Stratifies patients with brain metastases into three classes
• Class I: Karnofsky performance status (KPS) ≥ 70, < 65 years of
age with controlled primary & no extracranial metastases
Class III: KPS < 70
Class II: all others
(Gaspar et al., 1997)
7. Graded prognostic assessment (GPA)
• First published in 2008 based on patients from five
randomized RTOG trials
• Four prognostic factors—age, KPS, extracranial metastases &
number of brain metastases
• 2010: Diagnosis-Specific Graded Prognostic Assessment (DS-GPA)
• Breast GPA: tumor subtypes included
• molGPA: GPA incorporates molecular factors (EGFR and ALK gene
alterations in NSCLC & BRAF status in melanoma)
Sperduto, Paul W et al. “Survival in Patients With Brain Metastases: Summary Report on the Updated Diagnosis-Specific Graded Prognostic Assessment
and Definition of the Eligibility Quotient.” Journal of clinical oncology (2020): 3773-3784
8. Breast GPA
Sperduto, Paul W et al. “Beyond an Updated Graded Prognostic Assessment (Breast GPA): A Prognostic Index and Trends in Treatment and Survival in Breast Cancer Brain Metastases
From 1985 to Today.” International journal of radiation oncology, biology, physics vol. 107,2 (2020): 334-343
Kaplan Meier Curves for Survival by Breast GPA
GPA of 0: Worst prognosis
GPA of 4.0: Best prognosis
9. SRS: What is the maximum tolerated
dose?
Purpose: To determine the maximum tolerated dose of single fraction radiosurgery
in patients with recurrent previously irradiated primary brain tumors & brain
metastases.
10. RTOG PROTOCOL 90-05
• Between 1990–1994
• 156 patients : 36% recurrent primary brain tumors (median
prior dose 60 Gy) & 64% recurrent brain metastases (median
prior dose 30 Gy)
• Initial radiosurgical doses :18 Gy for tumors < 20 mm, 15 Gy
for tumors 21–30 mm, &12 Gy for 31–40 mm in maximum
diameter
11. RTOG PROTOCOL 90-05
• Doses escalated in 3 Gy, & incidence of irreversible grade 3-
5 Radiation Therapy Oncology Group (RTOG) neurotoxicity
assessed.
• Maximum tolerated doses: 24 Gy for tumors < 20 mm,
18 Gy for tumors 21–30 mm
15 Gy for 31–40 mm
• For tumors < 20 mm, investigators’ reluctance to escalate to
27 Gy, rather than excessive toxicity, determined the
maximum tolerated dose
12. Critical Structures & Tolerance for
Intracranial SRS
Intracranial Stereotactic Radiosurgery, Jason P. Sheehan, L. Dade Lunsford, 3rd edition, Page 72
13. What are the indications for SRS alone for
patients with intact brain metastases?
Three randomized controlled trials (RCTs) compared SRS
alone to SRS plus WBRT
• JROSG 99-1 (Aoyama et al. 2006)
• MDACC (Chang et al. 2009)
• NCCTG (Brown et al. 2016)
Two RCTs compared local therapy alone (SRS or surgery) to
local therapy plus WBRT.
• EORTC 22952-26001 (Kocher et al. 2011)
• Hong et al. 2019
14. • Randomized multi-institution trial by Japanese Radiation
Oncology Study Group (JROSG 99-1)
• 132 patients with 1–4 brain metastases (dia. < 3 cm) & KPS
≥70
• SRS (18–25 Gy/1 fraction) vs. WBRT(30 Gy/10 fractions)
followed by SRS
15. JROSG 99-1 (Aoyama et al. 2006)
• Addition of WBRT reduced rate of new metastases (64% vs.
42%), need for salvage brain treatment, & improved 1-year
recurrence rate (47%vs. 76%).
• No difference in OS (~8 months), neurologic or KPS
preservation, or Mini-Mental State Examination (MMSE)
score
16. • Randomized trial by MD Anderson Cancer Center
• 58 patients with 1–3 brain metastases and KPS ≥70
• SRS (15–24 Gy/1 fraction) vs. SRS + WBRT
• Formal neurocognitive testing
17. MDACC (Chang et al. 2009)
• Trial stopped early: Decline in memory and learning at 4
months with WBRT by Hopkins Verbal Learning Test (52%
vs. 24%).
• WBRT associated with improved LC (100% vs. 67%) &
distant brain control (73% vs.45%) at 1 year
• Significantly longer OS with SRS alone (15 vs. 6 months)-
Patients in this arm received more salvage therapy including
repeat SRS (27 vs. 3 retreatments)
18. • Prospective phase III randomized trial by North Central Cancer
Treatment Group (NCCTG)
• SRS alone or SRS+WBRT for 1–3 brain metastases
• Primary endpoint: Neurocognitive deterioration at 3 months
• 213 participants showed less cognitive deterioration at 3 months
after SRS alone (63.5%) compared to SRS and WBRT (91.7%) p <
0.001
JAMA. 2016;316(4):401-409
19. NCCTG (Brown et al. 2016)
• Time to intracranial failure: Significantly shorter for SRS
alone (HR 3.6; p < 0.001)
• No significant difference in OS at 10.4 months for SRS alone
and 7.4 months for SRS plus WBRT (p = 0.92)
20. J Clin Oncol. 2011 Jan 10; 29(2): 13 J Clin
Oncol. 2011 Jan 10; 29(2): 134–141 4–
141
• Randomized phase III trial of the European Organisation for
Research and Treatment of Cancer (EORTC)
• 359 patients with 1-3 brain metastases & WHO performance status
(PS) of 0 to 2 treated with complete surgery or radiosurgery
• Randomly assigned to adjuvant WBRT (30 Gy in 10 fractions) or
observation (OBS)
• Primary end point: Time to WHO PS deterioration to >2
J Clin Oncol. 2011 Jan 10; 29(2): 134–141
21. EORTC 22952-26001 (Kocher et al. 2011)
• Median time to WHO PS >2 : 10.0 months (95% CI, 8.1 to 11.7
months) after OBS & 9.5 months (95% CI, 7.8 to 11.9 months) after
WBRT (P=.71)
• Overall survival: Similar in WBRT & OBS arms (median, 10.9 v 10.7
months, respectively; P= .89)
• WBRT reduced 2-year relapse rate both at initial sites (surgery: 59% to
27%, P < .001; radiosurgery: 31% to 19%, P = .040) & at new sites
(surgery: 42%to 23%, P = .008; radiosurgery: 48% to 33%, P = .023).
22. EORTC 22952-26001 (Kocher et al. 2011)
• Intracranial progression caused death in 78 (44%) of 179 patients
in OBS arm & in 50 (28%) of 180 patients in WBRT arm
• After radiosurgery or surgery of a limited number of brain
metastases, adjuvant WBRT reduces intracranial relapses &
neurologic deaths but fails to improve the duration of functional
independence & OS
23. • Randomized phase III trial
• 215 patients with 1-3 melanoma brain metastases locally
treated by either surgery and/or SRS
• Randomly assigned to adjuvant WBRT or observation (OBS)
• Primary end point: Distant intracranial failure within 12 months
• Secondary end points: Time to intracranial failure, survival, &
time to deterioration in PS
J Clin Oncol 37:3132-3141
24. Hong et al.(2019)
• Forty-two percent of patients in WBRT group & 50.5% in observation
developed distant intracranial failure within 12 months (odds ratio,
0.71;95% CI, 0.41 to 1.23; P = .22)
• At 12 months, 41.5% of patients in WBRT group & 51.4% of patients
in observation group had died (P = .28), with no difference in rate of
neurologic death.
• Median time to deterioration in PS: 3.8 months after WBRT & 4.4
months with observation (P = .32)
• After local treatment of 1-3 melanoma brain metastases, adjuvant
WBRT does not provide clinical benefit in terms of distant intracranial
control, survival, or preservation of PS
25. “Strong recommendations are made for SRS for patients with limited brain
metastases and Eastern Cooperative Oncology Group performance status 0 to 2”
26.
27. Indications for observation, preoperative SRS,
or postoperative SRS or WBRT in patients
with resected brain metastases
28.
29. Case 01: A 37-year-old woman treated for carcinoma ovary was evaluated for headache and vomiting. MRI Brain revealed a
lesion in the left cerebellar hemisphere suggestive of solitary brain metastasis. She was treated with SRS alone. A dose of 16
Gy was delivered in single fraction by Conformal Radiotherapy using 9 non-coplanar beams.
30. Case 02: A 51-year-old woman with HER 2 positive breast cancer, post-surgery, chemotherapy and anti-HER-2 therapy was
evaluated for vertigo. MRI brain revealed 4 lesions (involving posterior fossa, bilateral frontal regions and left parietal lobe)
suggestive of metastasis. She underwent surgical excision of all 4 metastatic brain lesions. Histopathology review was
consistent with metastasis from invasive carcinoma breast, positive for Estrogen receptor (Allred sore 7), Progesterone
receptor (Allred sore 5) and Her-2 Neu protein (score 3+). Postoperatively she was treated with Linac based Volumetric
Modulated Arc Therapy(VMAT) for her brain metastasis. The cerebellar and right frontal lesions were treated with 25 Gy in 5
fractions. Left frontal and left parietal lesions were treated with a dose of 20 Gy/single fraction.
31. Primary malignant brain tumors
• First-line treatment of Glioblastoma: Maximum resection
followed by adjuvant chemoradiation with temozolomide as
defined through the Stupp trial (Stupp et al. 2005)
• Dose: 60 Gy in 30 fractions
• For elderly patients multiple RCTs (Perry et al. 2017; Roa
2004, 2015) established similar efficacy with shorter
hypofractionated schedules (e.g., 40 Gy in 15 fractions or 25
Gy in 5 fractions)
32. SRS as part of upfront treatment of High-
Grade Gliomas
RTOG 93-05 compared then-conventional treatment
(radiation and carmustine) with and without upfront SRS
boost in patients with GBM <4 cm in diameter & found no
difference in survival (13.5 vs. 13.6 months)
33. SRS for recurrent High-Grade Gliomas
No RCTs comparing radiosurgery to alternative or additional
therapies, including repeat surgery, further chemoradiation
(standard fractionation), or best supportive care
34. 32-year-old male underwent craniotomy and decompression in 2017 for left frontal high-grade glioma. He received postoperative
radiotherapy by 3D Conformal Technique - 5940cGy in 33 fractions with concurrent and adjuvant Temozolomide. 5 years after
treatment he underwent revision surgery for recurrence. Histopathology was reported as Astrocytoma grade 4, IDH mutant and he
was re-irradiated with Volumetric Modulated Arc Therapy- 25 Gy in 5 fractions.