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Carys Thomas, Salvatore Di Maio, Roy Ma, Emily Vollans, Christina Chu, M.Math., Brenda Clark, Richard Lee, Michael McKenzie, Montgomery Martin and Brian Toyota

Object

The goal in this study was to evaluate hearing preservation rates and to determine prognostic factors for this outcome following fractionated stereotactic radiotherapy (FSRT) of vestibular schwannoma.

Methods

Thirty-four consecutive patients with serviceable hearing who received FSRT between May 1998 and December 2003 were identified. Clinical and audiometry data were collected prospectively. The prescription dose was 45 Gy in 25 fractions prescribed to the 90% isodose line. The median follow-up duration was 36.5 months (range 12–85 months). The actuarial 2- and 4-year local control rates were 100 and 95.7%, respectively. Permanent trigeminal and facial nerve complications were 0 and 6%, respectively. The actuarial 2- and 3-year serviceable hearing preservation rates were both 63%. The median loss in speech reception threshold was 15 dB (range −10 to 65 dB). The radiotherapy dose to the cochlea was the only significant prognostic factor for hearing deterioration. Radiotherapy dose to the cochlear nucleus, patient age, sex, pre-FSRT hearing grade, tumor volume, and intracanalicular tumor volume failed to show any significance as prognostic factors.

Results

Five cases were replanned with four different radiotherapy techniques (namely arcs, dynamic arcs, static conformal fields, and intensity-modulated radiotherapy), with the cochlea defined as an organ at risk. In all cases, replanning resulted in statistically significant reduction in radiation to the cochlea (p = 0.001); however, no single replanning technique was found to be superior.

Conclusions

The radiation dose to the cochlea is strongly predictive for subsequent hearing deterioration. It is essential for the cochlea to be outlined as an organ at risk, and for radiation techniques to be optimized, to improve long-term hearing preservation.

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Salvatore Di Maio and Ryojo Akagami

Object

The best management strategy for small-to medium-sized vestibular schwannomas (VSs) remains controversial between observation, radiation, and microsurgical resection (surgery). The authors undertook a prospective observational cohort study comparing all 3 therapeutic modalities in patients with VSs, focusing on quality of life (QOL) outcomes.

Methods

All patients in the study completed the 36-Item Short Form Health Survey at regular intervals, with a mean follow-up of 31.8 months. Two hundred five (77.7%) of 264 patients completed questionnaires, including 47 who underwent observation, 48 who received either linear accelerator radiosurgery or fractionated radiotherapy (radiation group), and 134 who underwent surgery (of whom 37 had tumors > 3 cm in diameter). Patients allocated to the observation group had smaller tumors than those in the other groups (mean 1.3 cm; p < 0.001). Patients who received radiation were older than patients in the other groups (mean 60.0 years; p < 0.001).

Results

There were no baseline QOL differences between the observation, radiation, and surgery (tumors ≤ 3 cm) groups. Quality of life remained unchanged for the observation and radiation groups throughout the follow-up period. In the surgery group with tumors ≤ 3 cm, a significant improvement in total score and composite mental dimension was observed at 24 months. In the surgery group with tumors > 3 cm, there was an early improvement in composite mental dimension at 1.5 months, as well as at 24 months; total score and composite physical dimension were improved at 24 months in this group as well.

Conclusions

Based on the current management protocol, patients with VSs enjoy similar QOL throughout the follow-up period after undergoing observation, radiation therapy, or surgery.

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Salvatore Di Maio, Luigi M. Cavallo, Felice Esposito, Vita Stagno, Olga Valeria Corriero and Paolo Cappabianca

Object

Whereas most pituitary adenomas are removable via the transsphenoidal approach, certain cases, such as dumbbell-shaped or suprasellar adenomas and recurrent and/or fibrous tumors, remain difficult to treat. The authors present their experience with the extended endoscopic endonasal approach to the suprasellar area in managing this subset of tumors, which are classically treated through a transcranial route.

Methods

From June 1997 to December 2008, 615 patients underwent endoscopic endonasal transsphenoidal surgery for pituitary adenomas in the Department of Neurosurgery of the Università degli Studi di Napoli Federico II. Of this group, 20 patients with pituitary adenomas needed an extended endoscopic endonasal transtuberculum/transplanum approach for tumor removal. Two surgical corridors were used during the transsphenoidal approach: 1) the conventional endosellar extraarachnoidal corridor and 2) a suprasellar transarachnoidal corridor.

Results

The extent of resection was gross total in 12 (60%) of the 20 patients, near total in 4 (20%), subtotal in 3 (15%), and partial in 1 (5%). Postoperative CSF leakage occurred in 1 patient. One patient experienced worsening of temporal hemianopsia.

Conclusions

The authors' initial results with the extended endoscopic approach to the suprasellar area for selected pituitary adenomas are promising and may justify a widening of the current classical indications for transsphenoidal surgery.

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Salvatore Di Maio, Nancy Temkin, Dinesh Ramanathan and Laligam N. Sekhar

Object

The role of surgery and adjuvant radiation therapy for cranial base chordomas is not well established. This meta-analysis measures the relationship of complete resection and type of adjuvant radiation therapy to 5-year progression-free survival (PFS) and overall survival (OS) of cranial base chordomas.

Methods

A systematic MEDLINE search (1999–present) yielded 23 observational studies and 807 patients who fit inclusion criteria. The following analyses were performed: 1) Kaplan-Meier 5-year PFS and OS compared based on the extent of resection and type of adjuvant radiation therapy using the log-rank method; 2) a random-effects model comparing 5-year PFS with complete or incomplete resection; and 3) paired z-test comparisons of weighted average 5-year OS and PFS grouped by type of adjuvant radiation therapy.

Results

The weighted average follow-up was 53.6 months. The weighted average 5-year PFS and OS were 50.8% and 78.4%, respectively. Complete resection conferred a higher 5-year PFS than incomplete resection from the random effects model (mean difference in PFS 20.7%; 95% CI 6.57%–34.91%). Patients with incomplete resection were 3.83 times more likely to experience a recurrence (95% CI 1.63–9.00) and 5.85 times more likely to die (95% CI 1.40–24.5) at 5 years versus patients with complete resection. There was no difference in 5-year OS by type of adjuvant radiation, although 5-year PFS was lower in patients receiving Gamma Knife surgery relative to carbon ion radiotherapy (p = 0.042) on paired z-test. No survival difference occurred between radiation therapy techniques on Kaplan-Meier analysis of compiled patient data.

Conclusions

Patients with complete resection of cranial base chordomas have a prolonged 5-year PFS and OS. Adjuvant proton-beam, carbon ion, and modern fractionated photon radiation therapy techniques offered a similar rate of PFS and OS at 5 years.