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Douglas Kondziolka, Phillip V. Parry, L. Dade Lunsford, Hideyuki Kano, John C. Flickinger, Susan Rakfal, Yoshio Arai, Jay S. Loeffler, Stephen Rush, Jonathan P. S. Knisely, Jason Sheehan, William Friedman, Ahmad A. Tarhini, Lanie Francis, Frank Lieberman, Manmeet S. Ahluwalia, Mark E. Linskey, Michael McDermott, Paul Sperduto and Roger Stupp

Object

Estimating survival time in cancer patients is crucial for clinicians, patients, families, and payers. To provide appropriate and cost-effective care, various data sources are used to provide rational, reliable, and reproducible estimates. The accuracy of such estimates is unknown.

Methods

The authors prospectively estimated survival in 150 consecutive cancer patients (median age 62 years) with brain metastases undergoing radiosurgery. They recorded cancer type, number of brain metastases, neurological presentation, extracranial disease status, Karnofsky Performance Scale score, Recursive Partitioning Analysis class, prior whole-brain radiotherapy, and synchronous or metachronous presentation. Finally, the authors asked 18 medical, radiation, or surgical oncologists to predict survival from the time of treatment.

Results

The actual median patient survival was 10.3 months (95% CI 6.4–14). The median physician-predicted survival was 9.7 months (neurosurgeons = 11.8 months, radiation oncologists = 11.0 months, and medical oncologist = 7.2 months). For patients who died before 10 months, both neurosurgeons and radiation oncologists generally predicted survivals that were more optimistic and medical oncologists that were less so, although no group could accurately predict survivors alive at 14 months. All physicians had individual patient survival predictions that were incorrect by as much as 12–18 months, and 14 of 18 physicians had individual predictions that were in error by more than 18 months. Of the 2700 predictions, 1226 (45%) were off by more than 6 months and 488 (18%) were off by more than 12 months.

Conclusions

Although crucial, predicting the survival of cancer patients is difficult. In this study all physicians were unable to accurately predict longer-term survivors. Despite valuable clinical data and predictive scoring techniques, brain and systemic management often led to patient survivals well beyond estimated survivals.

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Douglas Kondziolka

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Beatriz E. Amendola and Aizik L. Wolf

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Douglas Kondziolka

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Christopher P. Deibert and Douglas Kondziolka

Intrinsic meningiomas of the superior sagittal sinus pose a significant technical challenge, particularly in the posterior two-thirds of the sinus. Resection is curative but frequently is not possible because of the involvement of critical vascular structures. Here, the authors present the case of a 49-year-old woman with a recurrent meningioma located exclusively in the posterior two-thirds of the sagittal sinus. The patient was treated with a margin dose of 12 Gy and a maximum dose of 24 Gy to the length of the tumor, which measured 16 cm. Five years after treatment, the tumor remains stable and the patient is symptom free. This case demonstrates the unique role that stereotactic radiosurgery can play in the management of meningiomas that are surgically unresectable and have no accepted form of treatment. To the authors' knowledge, 16 cm also represents the longest segment of tumor treated using stereotactic radiosurgery.

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Neal Luther, Douglas Kondziolka, Hideyuki Kano, Seyed H. Mousavi, John C. Flickinger and L. Dade Lunsford

Object

The authors sought to better define the clinical response of patients who underwent stereotactic radiosurgery (SRS) for brain metastases located in the region of the motor cortex.

Methods

A retrospective analysis was performed in 2026 patients with brain metastasis who underwent SRS with the Gamma Knife between 2002 and 2012, and multiple factors that affect motor function before and after SRS were evaluated. Ninety-four patients with tumors ≥ 1.5 cm in diameter located in or adjacent to the motor strip were identified, including 2 patients with bilateral motor strip metastases.

Results

Motor function improved after SRS in 30 (31%) of 96 cases, remained stable in 48 (50%), and worsened over time in 18 (19%) instances. Forty-seven patients had no motor weakness prior to radiosurgery; 10 (22%) developed new Grade 3/5–4/5 weakness. Thirty (68%) of 44 patients with ≥ 3/5 pre-SRS weakness improved, 6 (14%) remained stable, and 8 (18%) worsened. Three of 5 patients with < 3/5 pre-SRS motor function improved. Motor deficits prior to SRS did not correlate with a worse outcome; however, worse outcomes were associated with larger tumor volumes. The median tumor volume in patients whose function improved or remained stable was 5.3 cm3, but it was 9.2 cm3 in patients who worsened (p < 0.05). Tumor volumes > 9 cm3 were associated with a higher risk of worsening motor function. Adverse radiation effects occurred in 5 patients.

Conclusions

Most intact patients with brain metastases in or adjacent to motor cortex maintained neurological function after SRS, and most patients with symptomatic motor weakness remained stable or improved. Larger tumor volumes were associated with less satisfactory outcomes.

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Oren Berkowitz, Kristen Jones, L. Dade Lunsford and Douglas Kondziolka

Object

The definition and determination of quality health care is an important topic. The purpose of this study was to develop a longitudinal method to define a quality procedure by creating a formal approach to pre- and postoperative outcomes documentation. The authors worked to define quality outcomes by first documenting the patient's condition. Goals were determined together by the surgeon and the patient and then were evaluated to see if those goals were met.

Methods

The population consisted of cancer patients with newly diagnosed metastatic brain disease who were scheduled to undergo stereotactic radiosurgery. Surgeons recorded perioperatively objective information related to preoperative goals, clinical findings, surgical performance and/or error, and whether goals were met. In addition, patients completed pre- and postprocedure questionnaires (Rand 36-Item Short-Form Health Survey 1.0 [SF-36]).

Results

Procedural goals, defined as completing radiosurgery without error or complication and same-day discharge, were met in all patients. The clinically predetermined goal of tumor palliation was met in all but 1 patient at follow-up. The SF-36 scores remained stable except for the general health domain, which was lower (p = 0.006).

Conclusions

Procedural goals can be defined and objectively measured serially. The authors think that quality care can be defined as a process that achieves predefined goals without significant error and maintains or improves health.

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Jason P. Sheehan, Robert M. Starke, David Mathieu, Byron Young, Penny K. Sneed, Veronica L. Chiang, John Y. K. Lee, Hideyuki Kano, Kyung-Jae Park, Ajay Niranjan, Douglas Kondziolka, Gene H. Barnett, Stephen Rush, John G. Golfinos and L. Dade Lunsford

Object

Pituitary adenomas are fairly common intracranial neoplasms, and nonfunctioning ones constitute a large subgroup of these adenomas. Complete resection is often difficult and may pose undue risk to neurological and endocrine function. Stereotactic radiosurgery has come to play an important role in the management of patients with nonfunctioning pituitary adenomas. This study examines the outcomes after radiosurgery in a large, multicenter patient population.

Methods

Under the auspices of the North American Gamma Knife Consortium, 9 Gamma Knife surgery (GKS) centers retrospectively combined their outcome data obtained in 512 patients with nonfunctional pituitary adenomas. Prior resection was performed in 479 patients (93.6%) and prior fractionated external-beam radiotherapy was performed in 34 patients (6.6%). The median age at the time of radiosurgery was 53 years. Fifty-eight percent of patients had some degree of hypopituitarism prior to radiosurgery. Patients received a median dose of 16 Gy to the tumor margin. The median follow-up was 36 months (range 1–223 months).

Results

Overall tumor control was achieved in 93.4% of patients at last follow-up; actuarial tumor control was 98%, 95%, 91%, and 85% at 3, 5, 8, and 10 years postradiosurgery, respectively. Smaller adenoma volume (OR 1.08 [95% CI 1.02–1.13], p = 0.006) and absence of suprasellar extension (OR 2.10 [95% CI 0.96–4.61], p = 0.064) were associated with progression-free tumor survival. New or worsened hypopituitarism after radiosurgery was noted in 21% of patients, with thyroid and cortisol deficiencies reported as the most common postradiosurgery endocrinopathies. History of prior radiation therapy and greater tumor margin doses were predictive of new or worsening endocrinopathy after GKS. New or progressive cranial nerve deficits were noted in 9% of patients; 6.6% had worsening or new onset optic nerve dysfunction. In multivariate analysis, decreasing age, increasing volume, history of prior radiation therapy, and history of prior pituitary axis deficiency were predictive of new or worsening cranial nerve dysfunction. No patient died as a result of tumor progression. Favorable outcomes of tumor control and neurological preservation were reflected in a 4-point radiosurgical pituitary score.

Conclusions

Gamma Knife surgery is an effective and well-tolerated management strategy for the vast majority of patients with recurrent or residual nonfunctional pituitary adenomas. Delayed hypopituitarism is the most common complication after radiosurgery. Neurological and cranial nerve function were preserved in more than 90% of patients after radiosurgery. The radiosurgical pituitary score may predict outcomes for future patients who undergo GKS for a nonfunctioning adenoma.