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Daniel A. N. Barbosa, Ricardo de Oliveira-Souza, Felipe Monte Santo, Ana Carolina de Oliveira Faria, Alessandra A. Gorgulho and Antonio A. F. De Salles

The neurosurgical endeavor to treat psychiatric patients may have been part of human history since its beginning. The modern era of psychosurgery can be traced to the heroic attempts of Gottlieb Burckhardt and Egas Moniz to alleviate mental symptoms through the ablation of restricted areas of the frontal lobes in patients with disabling psychiatric illnesses. Thanks to the adaptation of the stereotactic frame to human patients, the ablation of large volumes of brain tissue has been practically abandoned in favor of controlled interventions with discrete targets.

Consonant with the role of the hypothalamus in the mediation of the most fundamental approach-avoidance behaviors, some hypothalamic nuclei and regions, in particular, have been selected as targets for the treatment of aggressiveness (posterior hypothalamus), pathological obesity (lateral or ventromedial nuclei), sexual deviations (ventromedial nucleus), and drug dependence (ventromedial nucleus). Some recent improvements in outcomes may have been due to the use of stereotactically guided deep brain stimulation and the change of therapeutic focus from categorical diagnoses (such as schizophrenia) to dimensional symptoms (such as aggressiveness), which are nonspecific in terms of formal diagnosis. However, agreement has never been reached on 2 related issues: 1) the choice of target, based on individual diagnoses; and 2) reliable prediction of outcomes related to individual targets. Despite the lingering controversies on such critical aspects, the experience of the past decades should pave the way for advances in the field. The current failure of pharmacological treatments in a considerable proportion of patients with chronic disabling mental disorders is reminiscent of the state of affairs that prevailed in the years before the early psychosurgical attempts.

This article reviews the functional organization of the hypothalamus, the effects of ablation and stimulation of discrete hypothalamic regions, and the stereotactic targets that have most often been used in the treatment of psychopathological and behavioral symptoms; finally, the implications of current and past experience are presented from the perspective of how this fund of knowledge may usefully contribute to the future of hypothalamic psychosurgery.

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Rodrigo Couto Torres, Leonardo Frighetto, Antonio A. F. De Salles, Brian Goss, Paul Medin, Timothy Solberg, Judith Marianne Ford and Michael Selch

Object

The authors report the evolution of linear accelerator (LINAC)–based radiosurgery in the treatment of patients with intracranial meningiomas. They describe the technical aspects as well as clinical and radiological outcomes.

Methods

The authors performed a retrospective review of 161 patients harboring 194 intracranial meningiomas treated with various types of stereotactic irradiation at their institution between May 1991 and July 2002. Clinical and radiological follow-up data (mean follow-up period 32.5 months, range 6–125 months) were obtained in 128 patients (79.5%) with 156 meningiomas (80.4%). There were 88 women and 40 men whose mean age was 57.2 years (range 18–87 years). Stereotactic irradiation was the primary treatment in 44 patients, and 84 patients underwent resection prior to radiosurgery. Stereotactic radiosurgery (SRS) was used to treat 79 lesions and fractionated stereotactic radiotherapy (SRT) was used to treat 77. The mean dose for SRS was 1567 cGy (range 1200–2285 cGy) prescribed to a mean isodose line of 66.6% (range 50–90%). Stereotactic radiotherapy was delivered using a mean dose of 4839 cGy (range 2380–5400 cGy), prescribed to a mean isodose line of 89% (range 50–90%).

The mean follow-up periods were 40 and 24 months in SRS- and SRT-treated patients, respectively. Tumor control was achieved in 58 SRT-treated benign meningiomas (90%) and in 70 SRT-treated lesions (97.2%). In patients with atypical meningiomas a considerably poorer prognosis was seen. Clinical improvement or stabilization of symptoms was observed in the majority of patients. Symptomatic complications were limited to four patients (5%) treated with SRS and four (5.2%) treated with SRT.

Conclusions

Stereotactic irradiation techniques have changed the neurosurgical approach to intracranial meningiomas. Either SRS or SRT delivered as a primary treatment in selected cases of skull base lesions or as an adjuvant after conservative resection has improved the management of these complex intracranial tumors.

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Kristin J. Redmond, Simon S. Lo, Scott G. Soltys, Yoshiya Yamada, Igor J. Barani, Paul D. Brown, Eric L. Chang, Peter C. Gerszten, Samuel T. Chao, Robert J. Amdur, Antonio A. F. De Salles, Matthias Guckenberger, Bin S. Teh, Jason Sheehan, Charles R. Kersh, Michael G. Fehlings, Moon-Jun Sohn, Ung-Kyu Chang, Samuel Ryu, Iris C. Gibbs and Arjun Sahgal

OBJECTIVE

Although postoperative stereotactic body radiation therapy (SBRT) for spinal metastases is increasingly performed, few guidelines exist for this application. The purpose of this study is to develop consensus guidelines to promote safe and effective treatment for patients with spinal metastases.

METHODS

Fifteen radiation oncologists and 5 neurosurgeons, representing 19 centers in 4 countries and having a collective experience of more than 1300 postoperative spine SBRT cases, completed a 19-question survey about postoperative spine SBRT practice. Responses were defined as follows: 1) consensus: selected by ≥ 75% of respondents; 2) predominant: selected by 50% of respondents or more; and 3) controversial: no single response selected by a majority of respondents.

RESULTS

Consensus treatment indications included: radioresistant primary, 1–2 levels of adjacent disease, and previous radiation therapy. Contraindications included: involvement of more than 3 contiguous vertebral bodies, ASIA Grade A status (complete spinal cord injury without preservation of motor or sensory function), and postoperative Bilsky Grade 3 residual (cord compression without any CSF around the cord). For treatment planning, co-registration of the preoperative MRI and postoperative T1-weighted MRI (with or without gadolinium) and delineation of the cord on the T2-weighted MRI (and/or CT myelogram in cases of significant hardware artifact) were predominant. Consensus GTV (gross tumor volume) was the postoperative residual tumor based on MRI. Predominant CTV (clinical tumor volume) practice was to include the postoperative bed defined as the entire extent of preoperative tumor, the relevant anatomical compartment and any residual disease. Consensus was achieved with respect to not including the surgical hardware and incision in the CTV. PTV (planning tumor volume) expansion was controversial, ranging from 0 to 2 mm. The spinal cord avoidance structure was predominantly the true cord. Circumferential treatment of the epidural space and margin for paraspinal extension was controversial. Prescription doses and spinal cord tolerances based on clinical scenario, neurological compromise, and prior overlapping treatments were controversial, but reasonable ranges are presented. Fifty percent of those surveyed practiced an integrated boost to areas of residual tumor and density override for hardware within the beam path. Acceptable PTV coverage was controversial, but consensus was achieved with respect to compromising coverage to meet cord constraint and fractionation to improve coverage while meeting cord constraint.

CONCLUSIONS

The consensus by spinal radiosurgery experts suggests that postoperative SBRT is indicated for radioresistant primary lesions, disease confined to 1–2 vertebral levels, and/or prior overlapping radiotherapy. The GTV is the postoperative residual tumor, and the CTV is the postoperative bed defined as the entire extent of preoperative tumor and anatomical compartment plus residual disease. Hardware and scar do not need to be included in CTV. While predominant agreement was reached about treatment planning and definition of organs at risk, future investigation will be critical in better understanding areas of controversy, including whether circumferential treatment of the epidural space is necessary, management of paraspinal extension, and the optimal dose fractionation schedules.