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Marshall D.C.,University of California at San Diego | Marcus L.P.,University of California at Los Angeles | McCutcheon B.A.,Mayo Medical School | Goetsch S.J.,San Diego Gamma Knife Center | And 7 more authors.
Journal of Neuro-Oncology | Year: 2016

With escalating focus on cost containment, there is increasing scrutiny on the practice of multiple stereotactic radiosurgeries (SRSs) for patients with cerebral metastases distant to the initial tumor site. Our goal was to determine the survival patterns of patients with cerebral metastasis who underwent multiple SRSs. We retrospectively analyzed survival outcomes of 801 patients with 3683 cerebral metastases from primary breast, colorectal, lung, melanoma and renal histologies consecutively treated at the University of California, San Diego/San Diego Gamma Knife Center (UCSD/SDGKC), comparing the survival pattern of patients who underwent a single (n = 643) versus multiple SRS(s) (n = 158) for subsequent cerebral metastases. Findings were recapitulated in an independent cohort of 2472 patients, with 26,629 brain metastases treated with SRS at the Katsuta Hospital Mito GammaHouse (KHMGH). For the UCSD/SDGKC cohort, no significant difference in median survival was found for patients undergoing 1, 2, 3, or ≥4 SRS(s) (median survival of 167, 202, 129, and 127 days, respectively). Median intervals between treatments consistently ranged 140–178 days irrespective of the number of SRS(s) (interquartile range 60–300; p = 0.25). Patients who underwent >1 SRSs tend to be younger, with systemic disease control, harbor lower cumulative tumor volume but increased number of metastases, and have primary melanoma (p < 0.001, <0.001, <0.001, 0.02, and 0.009, respectively). Comparable results were found in the KHMGH cohort. Using an independent validation study design, we demonstrated comparable overall survival between judiciously selected patients who underwent a single or multiple SRS(s). © 2016 Springer Science+Business Media New York

Taich Z.J.,University of California at San Diego | Goetsch S.J.,San Diego Gamma Knife Center | Monaco E.,San Diego Gamma Knife Center | Carter B.S.,University of California at San Diego | And 3 more authors.
World Neurosurgery | Year: 2016

Background Stereotactic radiosurgery (SRS) is a minimally invasive surgical option for the treatment of trigeminal neuralgia (TN). Here we review our institutional experience to identify prognostic factors associated with pain relief after SRS. Methods 263 patients with TN treated at the University of California, San Diego/San Diego Gamma Knife (2001-2013) were followed for more than 6 months. Univariate and multivariate Cox proportional hazard models analysis of factors associated with outcome was performed. Results Of the 263 patients, 229 (87%) presented with classical idiopathic TN, 31 (12%) presented with atypical TN, and 4 (1%) presented with secondary TN. 143 (54%) had undergone prior treatment. Most patients were treated with 85 (52%) or 90 Gy (42%). 79% of the SRS treated patients experienced a favorable response (defined as Barrow Neurological Institute Pain Scale <3 pain relief), with a median time to relief of 2.5 months. In a multivariate analysis, diagnosis of classical TN, previous percutaneous procedures, and age older than 70 years were associated with favorable responses; classical TN was associated with sustained pain relief. Dose prescription >85 Gy and prior SRS were associated with bothersome facial numbness posttreatment. For patients presenting with classical TN, diagnosis of multiple sclerosis (MS) did not decrease the likelihood of pain relief after SRS. Conclusions Excellent TN pain relief was achieved with the delivery of 85 Gy in a single-shot, 4-mm isocenter SRS targeting the dorsal root entry zone. Patients with classical TN, with age older than 70 years, or who underwent previous percutaneous procedures were more likely to benefit from SRS. SRS is efficacious in patients with classical TN despite concurrent diagnosis of MS. © 2016 Elsevier Inc. All rights reserved.

Gonda D.D.,University of California at San Diego | Kim T.E.,University of California at San Diego | Goetsch S.J.,San Diego Gamma Knife Center | Kawabe T.,Katsuta Hospital Mito GammaHouse | And 12 more authors.
European Journal of Cancer | Year: 2014

Introduction Defining key prognostic factors for patients with cerebral metastases who underwent stereotactic radiosurgery (SRS) treatment will greatly facilitate future clinical trial designs. Methods We adopted a two-phase study design where results from one cohort were validated in a second independent cohort. The exploratory analysis reviewed the survival outcomes of 1017 consecutive patients (with 3610 metastases) who underwent Gamma radiosurgery at the University of California, San Diego (UCSD)/San Diego Gamma Knife Center (SDGKC). Multivariate analysis was performed to identify prognostic factors. Results were validated using data derived from 2519 consecutive patients (with 17,498 metastases) treated with SRS at the Katsuta Hospital. Results For the SDGKC cohort, the median overall survival of patients following SRS was 7 months. Two year follow-up data were available for 85% of the patients. Multivariate analysis found that patient age, Karnofsky Performance Status, systemic cancer status, tumour histology, number of metastasis and cumulative tumour volume independently associated with overall survival (p < 0.001). All statistical associations were validated by multivariate analysis of data derived from the Katsuta Hospital cohort. Conclusions This is the first integrated study that defined prognostic factors for SRS-treated patients with cerebral metastases using an inter-institutional validation study design. The work establishes a model for collaborative interactions between large volume centers and provides prognostic variables that should be incorporated into future clinical trial design. © 2014 Elsevier Ltd. All rights reserved.

Ott K.,San Diego Gamma Knife Center | Hodgens D.W.,San Diego Gamma Knife Center | Goetsch S.,San Diego Gamma Knife Center
Radiosurgery | Year: 2010

Introduction: Cluster headache is a particularly severe, periodic cephalalgia which is occasionally refractory to medical treatment. In the past, surgical lesions of the trigeminal nerve (TN) have produced initial relief in more than one-half of patients. Radiosurgical lesions of the TN have produced short-lived pain relief and perhaps increased toxicity. In this pilot study we added the sphenopalatine ganglion (SPG) as an additional target in an effort to extend the degree and length of pain relief. Methods: Over an 8-year period, we carried out 12 gamma knife radiosurgical treatments in 7 patients, treating only the TN or later both the TN and SPG contemporaneously. A 4-mm collimated shot was placed on the nerve root entry zone of the TN and a maximum dose of 85 to 103 Gy was prescribed. The SPG was radiated in the pterygopalatine fossa using an 8-mm collimated shot and maximum dose of 85 to 97 Gy. Results: One patient with three treatments to the TN enjoyed immediate and complete relief for 5, 22, and 25 months. Four of 5 patients with radiation of both the TN and SPG experienced pain relief for 8 and 30 months, or are continuing to enjoy pain relief 7, 18, and 22 months after treatment or re-treatment at the last follow-up. Most patients reported facial paresthesias following radiation. No profound numbness or deafferentation pain was experienced. Conclusions: These results, in some respects, reflect the morbidity and pain relief experience of Gamma Knife® radiosurgery for classical trigeminal neuralgia. The addition of the SPG as a target may prove to be valuable and has not increased the morbidity of treatment. © 2010 S. Karger AG.

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