PROPOSAL:Stereotactic radiosurgery (SRS) for the management of brainstem metastasis. CLINICAL CASE:An 81-year-old female with good performance status (Karnofsky performance status of 90 %) and a history of metastatic small cell lung cancer to the brain, lung, and pleura presents with a new single brainstem metastasis, measuring 1.27 cm in its largest diameter with a volume of 1.52 cc (Fig. 1). The tumor was initially staged as cT4 cN3 cM1a, with lung and pleural metastases. She received first-line chemotherapy with carboplatin and etoposide, achieving a good response. Magnetic resonance imaging six months after the last chemotherapy cycle demonstrated three new brain metastases. She subsequently underwent whole-brain radiotherapy (WBRT), receiving a total dose of 35 Gy delivered in 14 fractions. All brain metastases showed a complete response after the treatment. Her current extracranial disease remains stable after first-line chemotherapy. On physical examination, she has no neurological deficits and denies experiencing new headaches, nausea, or any other new complaints. She is not taking steroids. The brainstem metastasis was diagnosed one year after the completion of WBRT.

BACKGROUND:Traditional treatment options for optic nerve sheath meningiomas (ONSMs) include observation, surgery, and radiation therapy; however, none of these has emerged as the definitive treatment of choice to date. Preliminary results on the application of hypofractionated radiosurgery have been quite promising in terms of preserving visual function and achieving local tumor control. OBJECTIVES:An exploratory trial was conducted to evaluate the safety and effectiveness of hypofractionated radiosurgery (25 Gy in 5 fractions) for ONSMs. METHODS AND MATERIALS:From May 2011 to May 2019, 50 patients with ONSMs were consecutively enrolled and treated with radiosurgery using the frameless CyberKnife system. Patients had median age of 49 years (19-78 years). All patients were treated using hypofractionated radiosurgery, receiving 5 fractions of 5 Gy each, for a total dose of 25 Gy, prescribed at the 75% to 85% isodose line. Patients were evaluated for visual function through visual acuity and visual fields examination, and for local control through volumetric measurement of the tumor. RESULTS:The median follow-up was 6 years (IQR, 4.7-9.7 years). All patients tolerated the treatment well, with only 4 (8%) experiencing a reduction in visual acuity. No additional acute or late radiation-induced toxicities were observed. No retinopathy was described. No patients had worsening of visual field function. No patients showed ONSMs progression on magnetic resonance imaging follow-up. CONCLUSIONS:In this exploratory trial, hypofractionated radiosurgery (25 Gy/5 fractions) for ONSMs appears safe and effective in terms of visual function and growth control, which may be validated in future multi-institutional study with longer term follow-up.

PURPOSE:During the last decades, in addition to tumor control, hearing preservation has become an important priority in the treatment of vestibular schwannoma (VS). Given that the potential advantages of hypofractionated radiosurgery (hRS) over single-session radiosurgery (RS) in terms of improved hearing outcomes remain unclear, this randomized trial aims to provide a robust answer to this question. METHODS AND MATERIALS:The present is a double-arm randomized clinical trial. The study started in 2011 and the last patient was enrolled in 2020. The minimum follow-up was 36 months. The trial involved patients with a diagnosis of sporadic VS with preserved hearing. One hundred and eight patients were enrolled. Participants were randomized to receive either hRS (18 Gy/3 consecutive fractions) or RS (most commonly 12 Gy/1 fraction). At each follow-up, clinical assessment, volumetric magnetic resonance imaging, and audiometry were evaluated. The primary endpoint was hearing sparing 36 months after RS or hRS. The maintenance of a serviceable hearing was defined according to the American Academy of Otorhinolaryngology Head and Neck Surgery classification. RESULTS:Of the 108 randomized patients, 100 (47 RS and 53 hRS) were included in the analysis (mean age, 55 years; 56% female). No significant differences between hRS and RS were found in terms of hearing preservation (hazard ratio, 1.083; [95% CI, 0.603-1.946], and P = .789), with pretreatment hearing status, age, and dose to cochlea being the only significant predictors. No other parameters, including tumor volume, were associated with hearing preservation. At a median follow-up of 62 months, local control was 92% (95% CI, 84.8%-96.5%). Treatment-related toxicity was mild or moderate, in general not exceeding National Cancer Institute Common Terminology Criteria for Adverse Events grade 2. CONCLUSIONS:To our knowledge, this is the first randomized clinical trial comparing 2 different radiosurgical regimens while focusing on hearing preservation. The study failed to demonstrate the potential advantages of hRS over RS with respect to hearing preservation. The volumetric analysis confirmed an excellent postradiosurgery tumor control rate for both RS and hRS groups. These results may guide the clinicians in the treatment schedule choice to preserve hearing in patients with VS.

Objective: The COVID-19 pandemic affected neuro-oncological patients and their caregivers regarding tumor care and emotional functioning, including Quality of Life (QoL). This study aimed to understand how COVID-19 affected their psychological state and the relations between patients and health personnel in neuro-oncology. Methods: A cross-sectional study was conducted on neuro-oncological patients and their caregivers. Results: A total of 162 patients and 66 caregivers completed the questionnaire. Altogether, 37.5% of patients perceived a greater risk of contracting COVID-19 compared to the general population. On a 0–10 scale, the patients’ tumor-related anxiety score was 5.8, and their COVID-19-related score was 4.6. The caregivers reported 7.7 and 5.5, respectively. QoL was described as at least good in 75% of both patients and caregivers; the caregivers’ care burden increased in 22.7% of cases during the pandemic, with no correlation with QoL. Future perception often changed, both in patients and caregivers. In 18% of cases, the cancer treatment schedule was changed, either by patient decision or by medical decision. However, 93.5% of patients were satisfied with their overall care. Conclusions: A considerable proportion of patients and caregivers still perceived the tumor disease as more burdensome than the pandemic, and their future as more uncertain. Such data suggest the need to build a productive alliance between patients and health professionals.

PURPOSE:to predict vestibular schwannoma (VS) response to radiosurgery by applying machine learning (ML) algorithms on radiomic features extracted from pre-treatment magnetic resonance (MR) images.METHODS:patients with VS treated with radiosurgery in two Centers from 2004 to 2016 were retrospectively evaluated. Brain T1-weighted contrast-enhanced MR images were acquired before and at 24 and 36 months after treatment. Clinical and treatment data were collected contextually. Treatment responses were assessed considering the VS volume variation based on pre- and post-radiosurgery MR images at both time points. Tumors were semi-automatically segmented and radiomic features were extracted. Four ML algorithms (Random Forest, Support Vector Machine, Neural Network, and extreme Gradient Boosting) were trained and tested for treatment response (i.e., increased or non-increased tumor volume) using nested cross-validation. For training, feature selection was performed using the Least Absolute Shrinkage and Selection Operator, and the selected features were used as input to separately build the four ML classification algorithms. To overcome class imbalance during training, Synthetic Minority Oversampling Technique was used. Finally, trained models were tested on the corresponding held out set of patients to evaluate balanced accuracy, sensitivity, and specificity.RESULTS:108 patients treated with Cyberknife® were retrieved; an increased tumor volume was observed at 24 months in 12 patients, and at 36 months in another group of 12 patients. The Neural Network was the best predictive algorithm for response at 24 (balanced accuracy 73% ± 18%, specificity 85% ± 12%, sensitivity 60% ± 42%) and 36 months (balanced accuracy 65% ± 12%, specificity 83% ± 9%, sensitivity 47% ± 27%).CONCLUSIONS:radiomics may predict VS response to radiosurgery avoiding long-term follow-up as well as unnecessary treatment.

Patients suffering from recurrent and residual grade 2 (WHO) meningiomas after subtotal excision should be considered as high-risk groups with an uncertain prognosis. Adjuvant radiotherapy seems to be the best approach to reduce disease progression. The primary aim of this phase II explorative, monocentric, single arm study was to evaluate the safety of adjuvant multisession radiosurgery (mRS) in this group of patients; the efficacy in terms of tumour local control was the secondary endpoint. Patients recruited from April 2017 to May 2019 were over 18 years old, had a histologically-documented intracranial recurrent or residual Grade 2 meningioma (WHO 2016) and a KPS > 70. Patients with NF2, concomitant neoplasm or pregnancy were excluded. Descriptive statistics were provided for categorical variables. Progression free survival (PFS) was modelled using the Kaplan–Meier method. Twenty-four patients were enrolled. All 24 patients underwent mRS: twenty-two patients received 28 Gy in 4 fractions, 2 patients received 24 Gy in 4 Treatment related adverse events (CTCAE 4.3) were limited to grade 2 in 1 patient (4.1%). At a median follow-up of 28 months, 8 patients (33.3%) had disease progression, either out-of-field or infield, compared with the planning target volume. Considering both infield and out-of-field progressions, 3-year PFS was 47% (95% confidence interval, CI, 22–69%); considering only the infield ones, 3-year PFS was 86% (95% CI 55–96%), and local control at last follow-up was 92%. mRS provides good local control of the tumour volume (TV) and is associated with a low rate of toxicity. These results call for further investigation to confirm favourable outcomes in patients with high-risk meningioma. NCT05081908, October 18, 2021, retrospectively registered.

Abstract Background The COVID-19 pandemic has inferred on patients (PTS) with cancer regarding disease evolution as well as the emotional and social functioning. The assessment of the needs and perceptions of PTS and their caregivers, is a priority to ensure an adequate standard in taking care and to promote the compliance to the treatments. The aim of this study is to understand how COVID-19 affects the emotional state and medical relationship in neuro-oncology. Material and Methods From Apr 2020 to Dec 2021 a prospective study was conducted on neuro-oncological PTS and their caregivers, including a 41-question and 16-question survey respectively. Results 162 PTS and 66 caregivers completed the questionnaire. 57.5% of PTS perceived grater risk , 37.5% the same risk and 5% lower risk of contracting the COVID-19 disease compared to the general population. 9.6% of PTS got SARS-CoV2 infection.Using a scale 0-10 for the assessment of anxiety, PTS experienced 5.8 (standard deviation, sd 2.6) as anxiety level related to tumor and 4.6 (sd 2.5) level about COVID-19 risk. For the most part there was no change in the treatment of cancer (81.5%). Due to the COVID-19 pandemic, 9.2% of PTS decided to delay anti-tumoral therapeutic schedule and 27.9% referred to be worried about going to hospital for consultation. Overall, 93.5% of PTS was satisfied with the treatments received. 52.6% of PTS felt different perception of the future during COVID-19, mostly referred like more uncertain. Caregivers experienced 7.7 (sd 2.1) anxiety level about tumor and 5.5 (sd 2.4) about COVID-19 risk. In 67.7% of caregivers the perception of the future has been changed, mostly towards greater insecurity. 75.0% of PTS described at least good Quality of Life (QoL), 65.4% of PTS declared to have sufficient resources to deal with the situation. There was a correlation between QoL and resources (P = 0.000). 77.3% of caregivers defined their care burden increased during the pandemic and 73.4% defined their QoL at least as good. We found a correlation between COVID-19 anxiety and anxiety for tumor diagnosis (ρ=0.53%, P = 0.000) as well as with future perception (Mann Whitney U test between PTS with different versus unchanged future perception, P = 0.001) in the PTS population. Conclusion The WHO definition of health refers to the biopsychosocial model. This model attributes the outcome of disease, as well as health, to the intricate and variable interaction of biological, psychological factors and social factors. In line with this model, it is essential to guarantee and improve the standard of care, also based to the real needs perceived by PTS and caregivers and to historical and social context. This is especially important in a pandemic period like COVID-19 is in which the good QoL can be compromised. An appropriate health-system organization and a special attention to patient doctor communication can make the different on QoL and the future perception.

To evaluate the use of radiotherapy (RT) for oligometastatic cancer (OMC) among radiation oncologists in Lombardy, Italy.