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Kai U. Frerichs, Philip E. Stieg and Robert M. Friedlander

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Philip E. Stieg

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Alexander M. Stessin, Allie Schwartz, Grigorij Judanin, Susan C. Pannullo, John A. Boockvar, Theodore H. Schwartz, Philip E. Stieg and A. Gabriella Wernicke

Object

The aim of this study was to examine the effect of postoperative external-beam radiation therapy (EBRT) on disease-specific survival in patients with nonbenign meningiomas.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2007 was queried for cases of resected Grades II (atypical) and III (malignant) meningioma. Disease-specific survival outcomes were determined using Kaplan-Meier survival analysis and Cox proportional hazards models. Logistic regression analysis was used to determine the likelihood of receiving EBRT for Grade II versus Grade III. Because atypical and malignant meningiomas underwent WHO reclassification in 2000, the authors carried out an additional analysis of outcomes of these tumors from 2000 to 2008.

Results

There were 657 patients included in the analysis; of these, 244 received adjuvant radiation. Compared with patients with Grade II meningioma, patients with Grade III disease were 41.9% more likely to receive EBRT after gross-total resection and 36.7% more likely to receive it after subtotal resection (95% CI 0.58–3.26). Controlling for grade, extent of resection, size and anatomical location of the tumor, year of diagnosis, race, age, and sex, adjuvant EBRT did not impart a survival benefit (HR 1.492; 95% CI 0.827–2.692). There was also no survival advantage to EBRT in an analysis of cases diagnosed after the WHO 2000 reclassification of meningiomas (HR 0.828; 95% CI 0.350–1.961).

Conclusions

The results of this population-based retrospective analysis demonstrate that the role of radiation remains unclear. They underscore the need for randomized prospective clinical trials to assess the usefulness of adjuvant EBRT in Grades II and III meningioma so as to define more precisely the subset of patients who may benefit from the addition of adjuvant radiation.

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A. Gabriella Wernicke, Menachem Z. Yondorf, Luke Peng, Samuel Trichter, Lucy Nedialkova, Albert Sabbas, Fridon Kulidzhanov, Bhupesh Parashar, Dattatreyudu Nori, K. S. Clifford Chao, Paul Christos, Ilhami Kovanlikaya, Susan Pannullo, John A. Boockvar, Philip E. Stieg and Theodore H. Schwartz

Object

Resected brain metastases have a high rate of local recurrence without adjuvant therapy. Adjuvant whole-brain radiotherapy (WBRT) remains the standard of care with a local control rate > 90%. However, WBRT is delivered over 10–15 days, which can delay other therapy and is associated with acute and long-term toxicities. Permanent cesium-131 (131Cs) implants can be used at the time of metastatic resection, thereby avoiding the need for any additional therapy. The authors evaluated the safety, feasibility, and efficacy of a novel therapeutic approach with permanent 131Cs brachytherapy at the resection for brain metastases.

Methods

After institutional review board approval was obtained, 24 patients with a newly diagnosed metastasis to the brain were accrued to a prospective protocol between 2010 and 2012. There were 10 frontal, 7 parietal, 4 cerebellar, 2 occipital, and 1 temporal metastases. Histology included lung cancer (16), breast cancer (2), kidney cancer (2), melanoma (2), colon cancer (1), and cervical cancer (1). Stranded 131Cs seeds were placed as permanent volume implants. The prescription dose was 80 Gy at a 5-mm depth from the resection cavity surface. Distant metastases were treated with stereotactic radiosurgery (SRS) or WBRT, depending on the number of lesions. The primary end point was local (resection cavity) freedom from progression (FFP). Secondary end points included regional FFP, distant FFP, median survival, overall survival (OS), and toxicity.

Results

The median follow-up was 19.3 months (range 12.89–29.57 months). The median age was 65 years (range 45–84 years). The median size of resected tumor was 2.7 cm (range 1.5–5.5 cm), and the median volume of resected tumor was 10.31 cm3 (range 1.77–87.11 cm3). The median number of seeds used was 12 (range 4–35), with a median activity of 3.82 mCi per seed (range 3.31–4.83 mCi) and total activity of 46.91 mCi (range 15.31–130.70 mCi). Local FFP was 100%. There was 1 adjacent leptomeningeal recurrence, resulting in a 1-year regional FFP of 93.8% (95% CI 63.2%–99.1%). One-year distant FFP was 48.4% (95% CI 26.3%–67.4%). Median OS was 9.9 months (95% CI 4.8 months, upper limit not estimated) and 1-year OS was 50.0% (95% CI 29.1%–67.8%). Complications included CSF leak (1), seizure (1), and infection (1). There was no radiation necrosis.

Conclusions

The use of postresection permanent 131Cs brachytherapy implants resulted in no local recurrences and no radiation necrosis. This treatment was safe, well tolerated, and convenient for patients, resulting in a short radiation treatment course, high response rate, and minimal toxicity. These findings merit further study with a multicenter trial.

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Alireza Shoakazemi, Alexander I. Evins, Justin C. Burrell, Philip E. Stieg and Antonio Bernardo

OBJECT

Surgical approaches to deep-seated brain pathologies, specifically lesions of the third ventricle, have always been a challenge for neurosurgeons. In certain cases, the transcallosal approach remains the most suitable option for targeting lesions of the third ventricle, although retraction of the fornices and wall of the third ventricle have been associated with neuropsychological and hypothalamic deficits. The authors investigated the feasibility of an interhemispheric 3D endoscopic transcallosal approach through a minimally invasive tubular retractor system for the management of third ventricular lesions.

METHODS

Three-dimensional endoscopic transtubular transcallosal approaches were performed on 5 preserved cadaveric heads (10 sides). A parasagittal bur hole was placed using neuronavigation, and a tubular retractor was inserted under direct endoscopic visualization. Following observation of the vascular structures, fenestration of the corpus callosum was performed and the retractor was advanced through the opening. Transforaminal, interforniceal, and transchoroidal modifications were all performed and evaluated by 3 surgeons.

RESULTS

This approach provided enhanced visualization of the third ventricle and more stable retraction of corpus callosum and fornices. Bayonetted instruments were used through the retractor without difficulty, and the retractor applied rigid, constant, and equally distributed pressure on the corpus callosum.

CONCLUSIONS

A transtubular approach to the third ventricle is feasible and facilitates blunt dissection of the corpus callosum that may minimize retraction injury. This technique also provides an added degree of safety by limiting the free range of instrumental movement. The combination of 3D endoscopic visualization with a clear plastic retractor facilitates safe and direct monitoring of the surgical corridor.

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Oszkar Szentirmai, Yuan Hong, Lino Mascarenhas, Al Amin Salek, Philip E. Stieg, Vijay K. Anand, Aaron A. Cohen-Gadol and Theodore H. Schwartz

OBJECT

The expansion of endovascular procedures for obliteration of cerebral aneurysms highlights one of the drawbacks of clip ligation through the transcranial route, namely brain retraction or brain transgression. Sporadic case reports have emerged over the past 10 years describing endonasal endoscopic clip ligation of cerebral aneurysms. The authors present a detailed anatomical study to evaluate the feasibility of an endoscopic endonasal approach for application of aneurysm clips.

METHODS

Nine human cadaveric head specimens were used to evaluate operative exposures for clip ligation of aneurysms in feasible anterior and posterior circulation locations. Measurements of trajectories were completed using a navigation system to calculate skull base craniectomy size, corridor space, and the surgeon's ability to gain proximal and distal control of parent vessels.

RESULTS

In each of the 9 cadaveric heads, excellent exposure of the target vessels was achieved. The transplanum, transtuberculum, and transcavernous approaches were used to explore the feasibility of anterior circulation access. Application of aneurysm clips was readily possible to the ophthalmic artery, A1 and A2 segments of the anterior cerebral artery, anterior communicating artery complex, and the paraclinoid and paraclival internal carotid artery. The transclival approach was explored, and clips were successfully deployed along the proximal branches of the vertebrobasilar system and basilar trunk and bifurcation. The median sizes of skull base craniectomy necessary for exposure of the anterior communicating artery complex and basilar tip were 3.24 cm2 and 4.62 cm2, respectively. The mean angles of surgical corridors to the anterior communicating artery complex and basilar tip were 11.4° and 14°, respectively. Although clip placement was feasible on the basilar artery and its branches, the associated perforating arteries were difficult to visualize, posing unexpected difficulty for safe clip application, with the exception of ventrolateral-pointing aneurysms.

CONCLUSIONS

The authors characterize the feasibility of endonasal endoscopic clip ligation of aneurysms involving the paraclinoid, anterior communicating, and basilar arteries and proximal control of the paraclival internal carotid artery. The endoscopic approach should be initially considered for nonruptured aneurysms involving the paraclinoid and anterior communicating arteries, as well as ventrolateral basilar trunk aneurysms. Clinical experience will be mandatory to determine the applicability of this approach in practice.

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Peter F. Morgenstern, Caitlin E. Hoffman, Gary Kocharian, Ranjodh Singh, Philip E. Stieg and Mark M. Souweidane

OBJECT

The optimal method for detecting recurrent arteriovenous malformations (AVMs) in children is unknown. An inherent preference exists for MR angiography (MRA) surveillance rather than arteriography. The validity of this strategy is uncertain.

METHODS

A retrospective chart review was performed on pediatric patients treated for cerebral AVMs at a single institution from 1998 to 2012. Patients with complete obliteration of the AVM nidus after treatment and more than 12 months of follow-up were included in the analysis. Data collection focused on recurrence rates, associated risk factors, and surveillance methods.

RESULTS

A total of 45 patients with a mean age of 11.7 years (range 0.5–18 years) were treated for AVMs via surgical, endovascular, radiosurgical, or combined approaches. Total AVM obliteration on posttreatment digital subtraction angiography (DSA) was confirmed in 27 patients, of whom the 20 with more than 12 months of follow-up were included in subsequent analysis. The mean follow-up duration in this cohort was 5.75 years (median 5.53 years, range 1.11–10.64 years). Recurrence occurred in 3 of 20 patients (15%). Two recurrences were detected by surveillance DSA and 1 at the time of rehemorrhage. No recurrences were detected by MRA. Median time to recurrence was 33.6 months (range 19–71 months). Two patients (10%) underwent follow-up DSA, 5 (25%) had DSA and MRI/MRA, 9 (45%) had MRI/MRA only, 1 (5%) had CT angiography only, and 3 (15%) had no imaging within the first 3 years of follow-up. After 5 years posttreatment, 2 patients (10%) were followed with MRI/MRA only, 2 (10%) with DSA only, and 10 (50%) with continued DSA and MRI/MRA.

CONCLUSIONS

AVM recurrence in children occurred at a median of 33.6 months, when MRA was more commonly used for surveillance, but failed to detect any recurrences. A recurrence rate of 15% may be an underestimate given the reliance on surveillance MRA over angiography. A new surveillance strategy is proposed, taking into account exposure to diagnostic radiation and the potential for catastrophic rehemorrhage.

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Malte Ottenhausen, Imithri Bodhinayake, Matei A. Banu, Philip E. Stieg and Theodore H. Schwartz

In 1955, Vincent du Vigneaud (1901–1978), the chairman of the Department of Biochemistry at Cornell University Medical College, was awarded the Nobel Prize for Chemistry for his research on insulin and for the first synthesis of the posterior pituitary hormones—oxytocin and vasopressin. His tremendous contribution to organic chemistry, which began as an interest in sulfur-containing compounds, paved the way for a better understanding of the pituitary gland and for the development of diagnostic and therapeutic tools for diseases of the pituitary. His seminal research continues to impact neurologists, endocrinologists, and neurosurgeons, and enables them to treat patients who had no alternatives prior to du Vigneaud’s breakthroughs in peptide structure and synthesis. The ability of neurosurgeons to aggressively operate on parasellar pathology was directly impacted and related to the ability to replace these hormones after surgery. The authors review the life and career of Vincent du Vigneaud, his groundbreaking discoveries, and his legacy of the understanding and treatment of the pituitary gland in health and disease.