Brain metastases are the commonest type

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1 Compehensive cance cae equies a multi-specialty appoach by Douglas Kondziolka, MD Co-diecto, Cente fo Image-Guided Neuosugey Bain metastases ae the commonest type of intacanial tumo. Each yea, the numbe of bain tumo metastases diagnosed fa outnumbes the total numbe of othe intacanial tumos. Futhe complicating the clinical pictue is the fact that between 21% and 86% of patients with metastases to the bain eithe have o will develop multiple lesions. In the United States alone, it is estimated that moe than 300,000 patients develop bain metastases each yea. With the advent of impoved cance teatments fo extacanial disease and the polifeation of neuoimaging technology, this oveall incidence is likely to ise. Pio to 1990, taditional teatment options fo patients with bain metastases included symptomatic medical management with coticosteoids, sugical esection, and whole bain adiation theapy (WBRT). Unfotunately, when used alone, these teatments wee associated with median suvivals of thee to six months. Although two andomized tials suggested impoved suvival and functional status with a combination of sugical esection and WBRT as compaed to WBRT alone, a thid and lage andomized tial demonstated no significant suvival benefit associated with the addition of sugical esection to WBRT. The development of teatment stategies that exceed histoically palliative measues and lengthen patients suvival has been the focus of much investigation. In most patients with metastatic bain disease, concomitant active systemic disease is common. As such, aggessive intevention coupled with a low mobidity ate is desiable. Since bain metastases ae fequently easily identifiable as well demacated lesions on eithe contast enhanced computeized tomogaphy (CT) o magnetic esonance imaging (MRI), they ae commonly amenable to steeotactic adiosugey. Radiosugey has become a valuable appoach fo such patients not only because of efficacy in the bain, but because the patient can immediately continue with extacanial cance cae. Success in both the bain and the body ae necessay fo the best patient outcomes. Although median suvivals emain poblematic, it is clea that moe and moe patients ae living longe when the bain and body cance ae bought into contol. The impotance of egula bain imaging (fo staging o follow-up), close collaboation with the patients medical oncologist and adiation oncologist, and attention to quality of life issues ae cucial. The development of a bain metastasis is a common complication of active systemic cance. The most common pimay tumos that metastasize to the bain ae lung, beast, melanoma, enal, and colon cance. In a summay of multiple autopsy studies, the mean pecentage of patients who develop bain metastasis fom the fou majo pimay cances ae as follows: 33% with a lung cance pimay develop a bain metastasis; 21% with beast; 48% with melanoma; and 11% with enal. Moe aely, othe cances such as postate, bladde, ovaian o sacoma metastasize intacanially. As cance patients live longe as a esult of impoved theapy fo extacanial disease, the incidence of bain metastasis is likely to incease. The aveage age fo developing a bain metastasis is appoximately 60 yeas old, although moe and moe younge patients ae being diagnosed, pedominantly with melanoma o beast cance. Lung cance is the most common souce of bain metastasis fo men. Howeve, beast cance is the most common souce fo women. Most types of cances appea to metastasize to the same degee in men as women. The distibution of metastasis locations coesponds appoximately to the size and blood flow pattens of the bain. This egional tumo distibution is as follows: 80% to 85% in the ceebal hemisphees; 10% to 15% in the ceebellum; 3% to 5% in the bainstem. Autopsy studies show that 60% to 85% of patients who die fom cance have multiple bain metastases. The time inteval between diagnosis of the pimay malignancy and a bain metastasis vaies substantially, and it appeas to be dependent in pat upon tumo histology. Patients with lung cance who go on to develop a bain metastasis tend to do so at a median of six to nine months afte diagnosis of the pimay. Renal bain metastases ae typically diagnosed 12 months fom detection of the pimay. Colon, beast, and melanoma bain metastases ae usually diagnosed two to thee yeas following discovey of the pimay malignancy. On the othe hand, some patients may pesent with symptomatic bain metastasis befoe any pimay has been diagnosed. A thoough evaluation of patients with the suggestion of bain metastasis on imaging studies should include a histoy and physical, chest, abdomen, and pelvic CT, and blood tests (See multi-specialty on page 8) Gamma Knife adiosugey (left), esection (middle), and the team appoach (ight), Ds. Douglas Kondziolka and John Flickinge.

2 d e p a t m e n t of neuosugey faculty Pofessos L. Dade Lunsfod, MD (Chaiman) P. David Adelson, MD (Vice Chaiman, Reseach) A. Leland Albight, MD C. Edwad Dixon, PhD Douglas Kondziolka, MD, MSc (Vice Chaiman, Education) John J. Moossy, MD Ian F. Pollack, MD Robet Sclabassi, MD, PhD William Welch, MD Howad Yonas, MD (Vice Chaiman, Academic Affais) Associate Pofessos Jeffey Balze, PhD Michael Hoowitz, MD Lay W. Jenkins, PhD Amin Kassam, MD Mingui Sun, PhD Haold B. Weiss, MS, MPH, PhD Assistant Pofessos David Bissonette, PA-C, MBA (Assistant Chaiman/Executive Diecto) Eleano Cason-Walte, PhD Donald J. Cammond, PhD Anthony Fabio, PhD Pete Geszten, MD, MPH Glenn Gobbel, DVM, PhD Ann H. Maitz, MSc Hideho Okada, MD, PhD Kevin Walte, MD Clinical Pofessos Joseph C. Maoon, MD (Vice Chaiman, CMI Division) Pete Sheptak, MD (Vice Chaiman, Clinical Affais) Clinical Associate Pofessos Adnan A. Abla, MD Matt El-Kadi, MD, PhD Daniel A. Wecht, MD Clinical Assistant Pofesso Ghassan K. Bejjani, MD Michael J. Rutigliano, MD, MBA Reseach Pofesso Edwin Nemoto, PhD Reseach Assistant Pofessos Ajay Nianjan, MCh Ronda Pindzola, PhD Reseach Instucto Wendy Fellows-Mayle, MA Clinical Associates Eic Altschule, MD Michael Moncman, MD David Zoub, MD Clinical Instucto Richad Spio, MD Reseach Associates Yue-Fang Chang, PhD Xiecheng Ma, MD Visiting Fellows/Reseach Associates Manabu Hatano, MD Juan José Matin, MD Kotao Nakaya, MD Daniel Pekuma, PhD Hulya Siin, MD Sait Siin, MD Magaet S. Wilson, PhD Hong Qu Yan, PhD U N I V E R S I T Y o f P I T T S B U R G H N E U R O S U R G E R Y N E W S C H A I R M A N S The case of the numb thumb In John Bunyan s classic allegoical tale, The Pilgim s Pogess, the pilgim s ventues eventually lead him to a site called the Slough of Despond. One can imagine a black bog that the pilgim descends into, pehaps analogous to the black depessions of a unipola depessive disode. I believe we physicians ae appoaching this slough of despond, as we ae consumed by egulation, micomanagement, bueaucacy, meddling, and wost of all, the wosening malpactice climate. Pennsylvania may be one of the wost malpactice states with no hope in sight fo tot efom, and no likelihood of state o fedeal legislation evamping this fightfully boken system. Sub-specialty physicians ae difficult to ecuit, many ae fleeing fom the slough. Let me give you a ecent bief vignette. Fotunately, by hook o by cook, I have escaped testifying in a medical malpactice action fo 29 yeas. Those cases that I have ageed to povide eview and testimony in ae few, and geaed towads the defense. My ecod was impeccable, since no case that I was eviewing had eve come to tial. I had neve been in a cout of law. My assessment: Bunyan s pilgim meets Fans Kafka. I came away fom this expeience congatulating ou specialty that even if we ae not pefect, if we an a pactice the way tial lawyes fo the plaintiffs and the defense un a tial, we would all be un out of town on a ail. The case epesented a potential unique twist on the cuent malpactice climate. Two tials wee in pocess at the same time. One, a seemingly obscue allegation that a espected and well-educated sugeon with extensive expeience pefeed one sugical incision vesus anothe, pehaps moe standad incision. The patient alleged that he suffeed an injuy because of the exposue elating to this, leading him to have a mino bit of sensoy dysfunction in one thumb, unable to wok at his pio job, although his company went out of business. The plaintiff s lawyes wanted $1.5 million. A second paallel allegation was made against the hospital, stating L E T T E R that the institution was negligent because at the time of e-cetification of this physician, they had not specifically esticted that physician fom using the incision with which he was comfotable afte moe than 200 pio case expeiences. A fome hospital administato (who had not actually been involved in a medical cente in 20 yeas, and who chages appoximately $500 pe hou fo his legal testimony) gave a video deposition. He stated the hospital was categoically negligent in failing to estict this sugeon s technique simply because at the time of e-cetification, a single allegation had been made in a simila case against that physician. At the time of the e-cetification pocess, the case simply epesented a wit, no tial, and no judgment (ultimately settled fo a small amount) was complete. The plaintiff s lawye subpoenaed me to be a witness of fact elative to the cedentialing pocess of the institution. On the stand, howeve, the plaintiff s lawye attempted to use me as an expet witness, ostensibly against the defendant neuosugeon, a fome colleague. Of couse, I testified that this sugeon had extensive expeience, and to the best of my knowledge had no significant poblems elated to his sugical appoach which was, in fact, used and taught by many centes, and which cetainly did not violate the standad of cae. The plaintiff s lawye continued to have me ead in examples of the liteatue, mostly opinion pieces in non-pee eviewed book chaptes, stating that the appoach used was widely condemned. Did I suppot the e-cedentialing of sugeons who used widely condemned pocedues? Of couse not. Howeve, do plaintiffs lawyes and thei patients set the standad of cae? Will ou specialties always be able to povide the appopiate neuosugical pimps who state opinions as if they epesented the standad of cae? Can you imagine the implications if evey plaintiff s complaint could include a dual chage, U N I V E R S I T Y o f P I T T S B U R G H neuosugeynews Edito: Douglas Kondziolka, MD Poduction Edito: Paul Stanick (See Thumb on page 8) All Univesity of Pittsbugh Neuosugey News content is copyighted and is meant solely fo the educational pupose of the eade. Please consult you physician befoe taking any medical actions, o contact the Univesity of Pittsbugh Depatment of Neuological Sugey at (412) You can also us at neuoinfo@upmc.edu. P A G E 2

3 CybeKnife Radiosugey fo Spinal Lesions by Pete C. Geszten, MD, MPH CybeKnife Pogam Diecto Steeotactic adiosugey fo bain tumos is a well-established technique. Its pecision is unpaalleled. Until ecently, the use of this poweful tool has been confined to the teatment of lesions within the skull. Standad teatment fo spinal tumos include adiotheapy alone, adionuclide theapy, adiotheapy plus systemic chemotheapy, homonal theapy, o sugical decompession and/o stabilization followed by adiotheapy. The ole of adiation theapy in the teatment of tumos the spine has been well established. A pimay facto that limits adiation dose with conventional adiotheapy is the low toleance of the spinal cod to adiation. Conventional extenal beam adiotheapy lacks the pecision to allow delivey of lage doses of adiation nea adiosensitive stuctues such as the spinal cod. If the adiation dose could be confined moe pecisely to the teatment volume, as is the case fo intacanial adiosugey, the likelihood of successful tumo contol should incease at the same time that the isk of spinal cod injuy is minimized. Steeotactic adiosugey now has a feasible delivey mechanism using an image-guided fameless steeotactic adiosugey delivey system known as the CybeKnife (Accuay, Inc., Sunnyvale, CA). The Univesity of Pittsbugh Medical Cente has pioneeed the use of the CybeKnife fo the teatment of spinal adiosugey and has the single lagest expeience in the wold. The CybeKnife system consists of a lightweight linea acceleato mounted on a obotic am. It diffes fom conventional fame-based adiosugey in thee fundamental ways. Fist, it efeences the position of the teatment taget to intenal adiogaphic featues such as the skull o implanted fiducials athe than a fame. Second, it uses eal-time x-ay imaging to establish the position of the lesion duing teatment and then dynamically bings the adiation beam into alignment with the obseved position of the teatment taget. Thid, it aims each beam independently, without a fixed isocente. Changes in patient position duing teatment ae compensated fo by adapted beam pointing athe than contolled thu igid immobilization. This allows the patient to be positioned comfotably duing the teatment without sedation. The CybeKnife system utilizes image-guided fameless obotic adiosugey. Two ceiling-mounted, diagnostic x-ay cameas ae positioned othogonally (90 offset) to acquie eal-time images of the patient s intenal anatomy duing teatment. The images ae pocessed automatically to identify adiogaphic featues and ae then egisteed to the teatment planning study to measue the position of the teatment site. The measued position is communicated though a eal-time contol loop to a obotic manipulato that aims a compact 6 MV linea acceleato. The system can adapt to changes in patient position duing teatment by acquiing tageting images epeatedly and then adjusting the diection of the teatment beam. The indications fo spinal adiosugey using the CybeKnife ae cuently evolving and will continue to evolve as clinical expeience inceases. We have teated ove 400 spinal tumos with the CybeKnife. Candidate lesions may be of benign o malignant histology. Spinal vascula malfomations ae also amenable to spinal adiosugey. Pio conventional extenal beam adiotheapy and/o sugey with o without instumentation does not peclude spinal adiosugey. Indeed, the majoity of ou patients have peviously undegone eithe sugey o extenal beam iadiation. Ove 90% of ou patients have expeienced impovement in pain following the pocedue. CybeKnife spinal adiosugey has been found to be feasible, safe, and effective fo the teatment of a wide vaiety of spinal lesions. The majo potential benefits of adiosugical ablation of spinal lesions ae shot teatment time in an outpatient setting with apid ecovey and good symptomatic esponse. This technique offes a successful theapeutic modality fo the teatment of a vaiety of spinal lesions as a pimay teatment o fo lesions not amenable to open sugical techniques, and medically opeable patients, lesions located in peviously iadiated sites, and as an adjunct to sugey. (Fa left) The CybeKnife adiosugey system. Note the two amophous silicone x-ay sceens positioned othogonally to the teatment couch. The couch can move to position the fiducials in font of the cameas; (nea left) the CybeKnife consists of a linea acceleato mounted on a 6-axis obotic manipulato that pemits a wide ange of beam oientations.

4 U N I V E R S I T Y o f P I T T S B U R G H N E U R O S U R G E R Y N E W S Spinal instumentation in oncology by Kevin A. Walte, MD Assistant Pofesso of Neuosugey In the past, stabilization and instumentation sugey was eseved fo a select few patients with metastases to the bony spine. Sugeons and oncologists felt that aggessive sugical pocedues wee inappopiate in patients with such limited expected life spans and incompatible with the concept of palliative cae. As cance teatments have evolved ove the last decade, sugeons have been foced to eassess these assumptions. As patients began to live longe with thei spinal metastatic disease, the limitations of the widely used consevative teatment paadigms became evident. The bulky back baces pescibed to help with spinal stability wee uncomfotable, educed patient mobility, educed quality of life and wee used with poo compliance. The high doses of nacotics needed fo even minimal pain elief in the setting of metastatic spinal instability geneally endeed patients stupoous and lethagic. Finally, in the ae instances whee sugey was employed it consisted only of decompessive laminectomy and was effective in elieving pain in less than 30% of patients. We now undestand that the failue of these ealy egimens was due to a misundestanding of the mechanisms of a patient s pain. Spinal epidual metastases cause pain by thee mechanisms. Fistly, tumo eosion though cotical bone sufaces of the spine defoms the bone coveing o peiosteum and inflames neve endings. Secondly, tumo expansion can compess spinal neves and poduce adicula pain in a fashion simila to a heniated disc. Lastly, the significant bone eosion and loss of stuctual stability associated with metastatic disease esults in abnomal movement and instability in the s p i n e. W h i l e a d i a t i o n theapy effectively addesses peiosteal pain and decompessive spinal sugey teats adicula pain, neithe of these modalities impoves o teats pain esulting fom the loss of stuctual stability fom bony metastases. In eality, decompessive laminectomy wosens spinal instability so it is not supising that many patients teated with that modality alone sometimes epot inceased post-opeative pain. In an effot to addess these failings, sugeons have tuned to the wide vaiety of devices appoved by the FDA fo spinal fixation in degeneative spine disease and applied these techniques to spine oncology patients. These constucts ae able to estoe immediate stability to the spine, effectively eplace bone eoded by tumo, peseve patient s mobility and function, and most impotantly damatically educe patient pain. Patient Evaluation Ove 95% of patients with spinal epidual metastases will pesent to medical attention with a chief complaint of back pain. Geneally this pain will have been pesent fo appoximately thee months befoe the patient seeks medical attention fo the poblem. At that time the tumo gowth will have pogessed to cause eithe a neuologic deficit o spinal instability in about 40% of patients. Oveall, up 20% of patients with cetain types of metastatic cance will expeience spinal metastases at some point duing the couse of thei disease. Geneally once a spine metastasis is suspected, a spine sugeon will ask fo an MRI scan of the entie spine. Spinal MRIs ae sensitive at finding even vey small metastatic tumos. The images also show the elationship of tumo to the spinal cod and neve oots. This infomation is citical in planning whethe o not sugey is necessay fo decompession. It also gives some hint as the degee of bony involvement occuing in the spine. Unlike the setting of degeneative spine disease whee thee is an excellent coelation between location of pain and location of spine pathology, pain in spinal metastatic disease is moe diffuse. An MRI limited to a single aea of the spine whee pain seems to be geatest Anteio and lateal thoacic spine x-ays of a patie vetebal body who failed veteboplasty stabilizatio stabilization with cabon fibe cages (below left) and on X-ay films. The small metal scew visible betwe togethe. The patient is alive, off nacotics, and in co will often undeestimate the amount of tumo involvement in the spine. To make a full detemination of bone eosion and spinal stability, howeve, an x-ay based imaging modality must be used. Theedimensional CT Scans with sagittal and coonal econstuctions ae optimal. Not only ae they sensitive fo bone eosion, they povide an excellent thee-dimensional econstuction of spinal anatomy alignment. Othe imaging modalities, such as flexion and extension adiogaphs may also be useful in limited cases to look fo abnomal motion, but most patients who have significant spinal instability have too much pain to complete these exams. Similaly, nuclea medicine bone scans, while sensitive fo initially detecting bony metastases in the spine, ae not paticulaly helpful in planning sugical inteventions due to thei lack of esolution. The pimay goal of most spinal instumentation sugey pefomed fo metastatic cance is pain eduction. In seveal lage published seies, an immediate and statistically significant eduction in pain was epoted in >95% of patients undegoing spinal stabilization as measued by visual P A G E 4

5 F A L L V O L U M E 5, N U M B E R 4 nt with multiple myeloma and collapse of the T6 n. Patient undewent anteio tumo esection and scew-od fixation. The stackable cages ae invisible en the T5 and T7 bodies holds the stackable cages mplete emission two-yeas post-opeatively. analog testing. These findings wee suppoted by significant eductions in nacotic equiements. Unfotunately patients who pesent with complete paaplegia ae unlikely to impove with sugey. In a vey select goup of patients who have an isolated spinal metastasis with no evidence of extaspinal disease o with cetain isolated tumos such as an isolated plasmacytoma sugical esection with adjuvant theapy may be cuative. These patients whee sugey is pefomed with cuative goal must be extensively evaluated pe and postopeatively. Even with the hope of cuative esection, ecuence is common. Sugical Techniques The appoach to spinal econstuction in patients with spinal epidual metastases can be pefomed via anteio o posteio appoaches o both. Because spinal metastases occu with equal fequency in each of the vetebal bodies and the thoacic spine epesents popotionally the lagest section of the spine, thoacic metastases ae most common. Geneally metastases affect eithe the vetebal body o pedicle. Metastatic tumos confined to the lamina o posteio elements ae less common. Theefoe anteio appoaches to the thoacic spine ae the most common opeations that the spine oncology sugeon is asked to pefom. The exposue is then in conjunction with a thoacic sugeon who assists with exposue of the chest and mobilization of the lung and if necessay mediastinal stuctues away fom the spine. Once this appoach is achieved the sugeon geneally has an excellent view to emove tumo compessing the anteio spine as well as to econstuct the spine aftewads. Moe ecently, a vaiety of cages have been developed which can be used to ebuild the anteio column of thoacic and lumba spine. These cages can be packed with bone gaft havested eithe fom the patient s hip o fom a cadave and can be cut o sized to custom fit the defect ceated by tumo emoval. Because of the customizable natue of these gafts it makes them an optimal adjuvant fo spine econstuction in the setting of metastatic disease whee the amount of spine to be eplaced and econstucted is quite vaiable. Among the best of the options fo intaspinal econstuction ae stackable cabon fibe cages. These cabon fibe cages exist in a modula fomat and can be stacked one on top anothe to exactly fill the size of the defect left by the tumo. Because they ae invisible on x-ay, they do not intefee with postopeative imaging to assess fusion ate and evaluation of tumo egowth postopeatively. They also povide excellent stuctual stability to the spine immediately postopeatively and have an ability to withstand loads seveal times geate than that of the nomal bone that they ae eplacing. Anteio intebody fusion devices ae futhe supplemented with additional stabilization devices. Anteio, thoacic and lumba plates and/o scew od fixation systems can be easily placed at the time of sugical decompession and intebody fusion cage placement. The anteio ods compess and stabilize the intebody gaft between the supeio and infeio vetebal bodies to pevent migation of the cage and impove constuct stability. Augmenting the fusion constuct using these maneuves fequently makes additional sugey via posteio appoach unnecessay. While the majoity of spinal metastases occu anteioly, posteio metastases to the lamina o posteio elements do occu. Additionally metastases that aise fom anteio vetebal body may gow though the pedicle to invade the posteio elements secondaily. In these instances emove of the tumo via a posteio appoach is geneally indicated. At that time instumentation to stabilize the spine to pevent futhe collapse and kyphosis is pefomed. While pedicle scew fixation, sublamina hook fixation and sublamina wie fixation have all been used in this disease setting, biomechanical studies have indicated that the igidity and stability of pedicle scew fixation is seveal times bette than that of hook based o wie based systems. In the setting of metastatic disease whee the majo goals is pain eduction via estoation of immediate stability, pedicle scews have clealy becomes state of the at. Because a vaiety of pedicle scew width and sizes ae now available, it s possible to place pedicle scews anywhee in the thoacic o lumba spine. Similaly pedicle scew constucts can be joined with tapeed ods to cevical constucts using lateal mass fixation. Because spinal metastatic tumos will often affect multiple levels of the spine the segmental natue of pedicle scew systems makes them an optimal choice fo stabilization acoss multiple levels. In ae instances patients will need to undego a combination of pocedues via an anteio and posteio appoach. In these cases anteio decompession and stabilization is pefomed initially since this is the oigin of compession of the majoity of patients. Posteio decompession fusion poceeds as a second pocedue o occus at a late date once the patient has ecoveed fom the fist opeation. In cetain patients a posteio appoach can be used effectively to pefom both posteio and anteio stabilization. This is accomplished by esecting the tumo fom the posteio using a tanspedicula oute to the anteio vetebal body. The anteio body is econstucted with methyl methacylate injected posteioly though the defect and posteio stabilization is then pefomed using pedicle scew ods. This combined technique is paticulaly appopiate fo the uppe thoacic spine which can be challenging to access though a thoacic incision. Outcomes In seveal pospective tials of spinal stabilization fo metastatic disease thee has been nea unifom impovement in pain scoes and quality of life fo patients postopeatively. The old assumptions that sugey would be too painful o too invasive fo patients with metastatic disease have poven unfounded. When metastatic disease is fist detected in the spine, a pompt evaluation of spinal stability is indicated. P A G E 5

6 U N I V E R S I T Y o f P I T T S B U R G H N E U R O S U R G E R Y N E W S Roles of Radiotheapy, Radiosugey in Initial Management of Bain Metastases John C. Flickinge MD Pofesso of Radiology Oncology and Neuological Sugey Douglas Kondziolka MD Pofesso of Neuological Sugey L. Dade Lunsfod MD Pofesso of Neuological Sugey Cuently, bain metastases become appaent in 20% to 40% of cance patients. As systemic theapy of cance continues to impove and cance patients live longe, this ate of metastases developing in a sanctuay site, like the cental nevous system, should incease. Unteated bain metastases ae associated with a suvival of one month mostly because of cental nevous system pogession. Taditionally, whole-bain adiotheapy, (WBXRT), has been the standad of cae fo the teatment of patients with bain metastasis patients, yielding suvivals of 3-6 months. WBXRT by itself is uneliable fo long-tem contol of bain metastases. Two pospective, andomized tials in solitay bain metastasis patients showed that moe aggessive local theapy with adding sugical esection to WBXRT impoved suvival. Because of the advantages of adiosugey (SRS) ove sugical esection in tems of costs, hospitalization, mobidity, motality, and wide applicability, SRS is being used moe fequently to teat patients with bain metastases. A andomized Univesity of Pittsbugh tial of adding adiosugey to WBXRT in 27 patients with 2-4 bain metastases demonstated damatically impoved local contol fo patients andomized to adiosugey plus WBXRT compaed to WBXRT alone (see figue 1). Because of the use of salvage adiosugey, a suvival advantage was not poven. The Radiation Theapy and Oncology Goup (RTOG) ecently completed a lage andomized tial of WBXRT with o without adiosugey in 333 patients with one to thee bain metastases <4cm in diamete, not involving bainstem. The addition of adiosugey significantly impoved local tumo contol and suvival in patients with solitay bain metastases (median suvival 6.5 months vs. 4.9 months without adiosugey). Radiosugey patients wee moe likely to have stable o impoved pefomance status at six months follow-up (43% vs. 27% without adiosugey). The guidelines fo when to use adiosugey, sugical esection, and whole bain P A G E 6 adiotheapy, alone o in combination ae not clealy established. Patients with lage, esectable, adioesistant bain metastases with mass effect symptoms unelieved by steoids, limited systemic disease and no containdications to sugey, will undoubtedly do bette with sugical esection alone. Patients with multiple bain metastases fom adiosensitive tumos, such as small cell lung cance, ae best managed with initial WBXRT, eseving adiosugey fo ecuence o failue. Patient with 1-2 small metastases fom elatively adioesistant tumos such as melanoma o enal cell cacinoma ae best managed with whole bain alone. Figue 2 shows a management pathway fo bain metastases patients that integates these modalities in the initial management of bain metastases. Reseach effots in the management of bain metastases at the Univesity of Pittsbugh include paticipation in the Ameican College of Sugeons Oncology Goup study of adiosugey vesus WBXRT plus adiosugey fo bain metastases, the ongoing assessment of gamma knife adiosugey fo bain metastases, the study of temozolomide plus whole bain adiotheapy in the management of bain metastases fom non-small cell lung cance, and peliminay wok in developing a potocol to study using dugs with antiangiogenic activity with adiosugey alone to attempt to educe subsequent seeding of new bain metastases. Recent Donations (All amounts: Up to $1,000) Childen s Neuosugey Chai United Way of Allegheny County Leksell Chai M. & Ms. Richad Dunn Pete E. Sheptak Chai Buns, White & Hickton Pete J. Jannetta Chai B.J. Mogan Geneal Fund Vela R. Chance Bettye Jo Haggad John Powes Roselynn Powes

7 CIRCL Establishes Community Poject Fund The Univesity of Pittsbugh s Cente fo Injuy Reseach and Contol (CIRCL) established a Regional Community Initiated Poject Fund this past yea and awaded $8000 to thee of Childen s Hospital of Pittsbugh s Family Community Centes (FCC): Baddock/Rankin, Mt. Olive, and Wilkinsbug. Baddock/Rankin: Home Safety fo Kids, ($3000). Help educe home-based fall-elated injuies and decease epoted and unepoted tauma injuies to childen. Wilkinsbug: Safe Home fo Kids, ($2500). Povide paents with usable items, education and follow-up to help pevent accidents in the home. Mt. Olive: Binging up Baby Safely, ($2500). Assist paents in adapting thei homes in ode to povide a safe envionment as thei child s skills & mobility develop. The objectives of this fund ae 1) to augment newe effots in injuy pevention and contol, 2) to povide a systematic means to tanslate eseach into community action, and 3) to povide outeach to the undeseved communities within the egion. Pefeence was given to poposals that focused on women and childen with an emphasis on bain and spinal cod injuy pevention and/o ehabilitation. CIRCL Successfully Completes Cente fo Disease Contol Site Visit The Cente fo Injuy Reseach and Contol successfully completed thei Cente fo Disease Contol Site visit on Septembe The agenda included special pesentations on Dental Tauma, Neuomuscula Reseach at the Cente fo Spots Medicine, Taumatic Bain Injuy, Inflicted Head Tauma in Infants, Neuoendocine Homones on Pathophysiology & Outcomes afte TBI, and Taumatic Bain Injuy CSF & Seum Banks. Reseach Vaccination with glioma associated antigen peptides in NF1 and TRP53 mutant mice that develop spontaneous glioblastoma. Hideho Okada, MD, PhD, National Bain Tumo Foundation ($15,000). Announcements Pete C. Gestzen, MD, was a guest lectue at the Annual Meeting of the Taiwan Neuospinal Society in Kaohsiung, Taiwan on July 23. His lectue was on adiosugey fo spinal tumos. D. Geszten was also a visiting pofesso at the Univesity of Viginia, Septembe 7-8. L. Dade Lunsfod, MD, seved as visiting pofesso at Michigan State Univesity in Lansing, MI, Septembe 8-9. Douglas Kondziolka, MD seved as visiting pofesso at the Mayo Clinic in Rocheste, MN, Septembe Welcome and Tansition Apil Engam, eseach assistant to Ian Pollack, MD; Kim Haiston, medical ecods coodinato; Paticia Quiin, CIRCL administato, Judith Kay Tisdale, tansciptionist to Ds. Kondziolka and Lunsfod; Valeie J. Tatteshall, medical tansciptionist, Jocelyn A. Bulge, administative assistant to William Welch, MD. F A L L V O L U M E 5, N U M B E R 4 & Jocelyn Koessle is now senio administative assistant to Howad Yonas, MD. Visitos Steve Haines, MD, pofesso and chaiman of the Depatment of Neuological Sugey at the Univesity of Minnesota seved as visiting pofesso hee Septembe 9. Mitchel S. Bege, MD, pofesso and chaiman of the Depatment of Neuological Sugey at the Univesity of Califonia, San Fancisco seved as visiting pofesso hee Septembe 22. Congatulations Baby boy (Nickhil, July 1) to Ajay Nianjan and wife Ranjana. Rhonda Pindzola, PhD, eceived a MPH degee fom the Univesity of Pittsbugh s Gaduate School of Public Health in August. Endowed Chais The Depatment of Neuological Sugey cuently has fou endowed chais at the Univesity of Pittsbugh poviding unique souces of suppot to individuals who have achieved pominence elative to patient cae, eseach and teaching. The fou chais and thei holdes ae the Las Leksell Chai (D. Lunsfod), The Walte Dandy Chai, (D. Pollack), The Pete J. Jannetta Chai (D. Yonas) and the Childen s Neuosugey Chai (D. A. Leland Albight.) A campaign is cuently undeway to fund a fifth chai, the Pete E. Sheptak Chai. This chai, honoing the caee of the depatment s cuent vice chaiman of clinical affais, will help pomote the caee of a next geneation neuosugeon. D. Sheptak has pefomed ove 50 yeas of clinical wok elated to spinal degeneative disodes, ceebovascula disease and bain tumos. Fo moe infomation on any of these endowed chais, please contact Wendy Edwads at (412) o Michelle Leive at (412) Upcoming Events Novembe 7-9: Steeotactic Neuosugey In You Pactice Taining Couse. Two-day taining couse designed fo neuosugeons and thei staff with an inteest in gowing thei pactice in neuo-oncology and functional neuosugey. The couse will be held at the Fou Seasons Hotel in Las Vegas, NV. Contact Kistie Maple at (412) fo moe infomation. Novembe 15-19: Pinciples and Pactice of Gamma Knife Radiosugey. Taining couse tageted at neuosugeons, adiation oncologists and medical physicists inteested in Gamma Knife adiosugey cetification. The next couse date is scheduled fo Januay 10-14, Contact Chalene Bake at (412) fo moe infomation. Januay 7-8: Minimally Invasive Endoscopic Sugey of the Canial Base and Pituitay Fossa Couse. Seies of lectues discussing appoaches fo endoscopic sugey of the canial base and pituitay fossa. Expets on the subject will pesent technical aspects of those opeations along with isks, benefits and outcomes. Live cases ae included. Contact Melissa Hawthone at (412) fo moe infomation. P A G E 7

8 N y U N I V E R S I T Y o f P I T T S B U R G H neuosugeynews Depatment of Neuological Sugey Univesity of Pittsbugh UPMC Pesbyteian/Suite B Lothop Steet Pittsbugh, PA (412) neuoinfo@upmc.edu Non-Pofit Oganization U.S. Postage PAID Pemit #4166 Pittsbugh, PA Patient Refeals (412) o l o g i c a l S u g u e e U h g n i v e s i t y o f P i t t s u b F A L L V O L U M E 5, N U M B E R 4 Multi-specialty appoach essential in cance cae (continued fom page 1) fo tumo makes such as cacinoembyonic antigen, fetal antigen 2, and postate specific antigen. Howeve, 16% to 35% of patients with bain metastasis at initial pesentation will have no identifiable pimay malignancy. Pevention of the development of bain metastases is a challenging task. Chemotheapy may be utilized to help contol extacanial disease but does not appea to alte the ate of intacanial metastasis. Radiosugey is a minimal access sugical technique designed to poduce a specific adiobiological effect within a shaply defined taget volume. A high dose of adiation is deliveed in a single session. At UPMC, thee Gamma Knife units ae used to povide bain adiosugey. Patients ae evaluated pomptly and scheduled quickly fo teatment. Local tumo contol ates following adiosugey appea to be equal o supeio to those affoded by esection and supeio to those afte adiotheapy alone. In the past, pogession of intacanial bain metastases was often the cause of death. Radiosugey offes effective local tumo contol, stabilized o impoved clinical symptomatology, and enhanced suvival. All of these adiosugical goals ae geneally achieved with low mobidity, low cost, and essentially zeo motality. Extacanial disease pogession is now moe often the cause of death. Such findings undescoe the theapeutic advances made in neuosugey fo teating patients with metastatic disease. Caniotomy and sugical esection has geneally been eseved fo patients with lage, solitay, accessible and symptomatic bain tumos. Fewe than 30% of patients with bain metastases ae eligible fo sugey. Because of the need fo iadiation following esection, and the delay inheent in estating chemotheapy o immunotheapy, the decision to esect a tumo should be made wisely, and with the undestanding that additional cance cae may be defeed. C H A I R M A N S (continued fom page 2) L E T T E R Case of the numb thumb i.e. malpactice of the physician and negligence on the pat of the institution fo the cedentialing pocess, specifically denying pivileges to do cetain pocedues in cetain ways because of a few opinions in book chaptes? The potential fo such a pecedent is mind-boggling. Final judgment: $680,000 fo the plaintiff in the case of the numb thumb. How did we physicians let ouselves come to this point? We ae taught in medical school and in the yeas of ou initial pactice to build hope and tust, to hone ou skills and to poviding the best cae possible. Did we know that we wee going to spend ou lives pacticing defensive medicine, pacticing CYA, and spending ou time in couts while both the plaintiffs and defense legal teams play the lottey? The tot system is inalteably boken. I suspect that only a conceted job action will help to estoe balance in the system. In the meantime, I popose that the tial lawyes be esticted to simply suing each othe. We can go on taking cae of patients without them. L. Dade Lunsfod, MD Las Leksell Pofesso Chaiman, Depatment of Neuological Sugey