Response To Pre-Operative Corticosteroids Predicts Durable Neurologic Improvement in Patients with Symptomatic Brain Metastases

2021 ◽  
Author(s):  
Stephen G Bowden ◽  
Christian Lopez Ramos ◽  
Barry Cheaney II ◽  
Emma Richie ◽  
Nasser K Yaghi ◽  
...  
Keyword(s):  
Visual Field ◽  
Brain Metastases ◽  
Average Duration ◽  
Descriptive Analysis ◽  
Motor Deficits ◽  
Neurologic Deficits ◽  
Obvious Association ◽  
Neurologic Function

Abstract Purpose: To determine the rate at which focal neurologic deficits respond to pre-operative corticosteroids in patients with brain metastases and whether such an improvement is predictive of long-term improvement in neurologic function following surgery. Methods: Patients with pathology-proven brain metastases who underwent open surgical resection between 2010 and 2019 were identified. Charts were reviewed to identify patients with deficits in language, visual field, or motor domains who received corticosteroids prior to surgery. Descriptive analysis compared characteristics between steroid responders and non-responders. Dosage and duration were binned into deciles and plotted against their corresponding response rates. Results: 96 patients demonstrated a visual field (13 patients), language (19), or motor (64) deficit and received dexamethasone in the week prior to surgery (average cumulative dose 42.66 mg; average duration 64.5 hours). 38.5% of patients’ deficits improved on neurologic exam prior to surgery. 82.3% of patients improved by follow-up. Motor deficits were most likely to improve (46.9%; p = 0.024). All 37 responders demonstrated durable improvement at follow-up whereas 42 of 59 (71%) of non-responders ultimately improved (p < 0.001). Average dosage and duration prior to response were 17.33 mg and 23.94 hours, respectively. All other clinical characteristics were similar between responders and non-responders. Conclusions: A response to steroids prior to surgery predicts long-term improvement for focal neurologic deficits related to brain metastases. Lack of such a response portends a somewhat less favorable prognosis. There is no obvious association between duration or intensity of therapy and response.

scholarly journals INNV-01. NEUROLOGIC IMPROVEMENT WITH CORTICOSTEROIDS PRIOR TO SURGERY IS PREDICTIVE OF DURABLE POST-OPERATIVE IMPROVEMENT IN MOTOR DEFICITS DUE TO BRAIN METASTASES

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii116-ii116
Author(s):  
Stephen Bowden ◽  
Barry Cheaney ◽  
Nasser Yaghi ◽  
Daniel Munger ◽  
Christian Lopez Ramos ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Clinical Characteristics ◽  
Mass Effect ◽  
Motor Dysfunction ◽  
Motor Deficits ◽  
Chi Square ◽  
Sustained Improvement ◽  
Neurologic Function

Abstract Corticosteroids reduce vasogenic cerebral edema and are thought to improve related neurologic deficits or symptoms of increased intracranial pressure. Brain metastases are typically associated with a large amount of edema and, consequently, come with a disproportionate degree of mass effect that may cause such deficits. There remains no standard approach to pre-operative corticosteroid therapy, nor is it understood what clinical characteristics are associated with a neurologic response to pre-operative steroids. We examined characteristics of steroid responders versus non-responders and, further, evaluated whether a response to preoperative steroids is predictive of durable improvement in neurologic function. Patients with pathology-proven brain metastases who underwent open surgical resection between 2009 and 2019 were identified from departmental records. Charts were reviewed to identify patients with motor dysfunction who received corticosteroids prior to surgery. Multiple patient and clinical characteristics were extracted and compared using student t-, chi-square, and Fisher’s exact tests. 90 patients exhibited pre-operative motor deficits, 69 of whom received corticosteroids prior to surgery (dose 2 – 112 mg; median 25 mg). 34 patients neurologic function improved prior to surgery, whereas 35 patients had no demonstrable improvement. All 34 patients (100%) whose motor function improved pre-operatively with steroids had sustained improvement at follow-up, whereas 27 of 35 (77%) patients who did not improve pre-operatively were better at follow-up (p = 0.005). All other clinical characteristics were similar between responders and non-responders. All motor deficits related to brain metastases that responded to steroids prior to surgery demonstrated durable improvement at follow-up, suggesting such an improvement portends a favorable long-term functional outcome. Conversely, a failure to improve with steroid therapy confers a more guarded prognosis.

scholarly journals Parenteral artemisinins are associated with reduced mortality and neurologic deficits and improved long-term behavioral outcomes in children with severe malaria

BMC Medicine ◽  
2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Andrea L. Conroy ◽  
Robert O. Opoka ◽  
Paul Bangirana ◽  
Ruth Namazzi ◽  
Allen E. Okullo ◽  
...  
Keyword(s):  
Executive Function ◽  
Hospital Mortality ◽  
Cerebral Malaria ◽  
Severe Malaria ◽  
Behavioral Outcomes ◽  
Artemisinin Derivatives ◽  
Neurologic Deficits ◽  
Adjusted Scores

Abstract Background In 2011, the World Health Organization recommended injectable artesunate as the first-line therapy for severe malaria (SM) due to its superiority in reducing mortality compared to quinine. There are limited data on long-term clinical and neurobehavioral outcomes after artemisinin use for treatment of SM. Methods From 2008 to 2013, 502 Ugandan children with two common forms of SM, cerebral malaria and severe malarial anemia, were enrolled in a prospective observational study assessing long-term neurobehavioral and cognitive outcomes following SM. Children were evaluated a week after hospital discharge, and 6, 12, and 24 months of follow-up, and returned to hospital for any illness. In this study, we evaluated the impact of artemisinin derivatives on survival, post-discharge hospital readmission or death, and neurocognitive and behavioral outcomes over 2 years of follow-up. Results 346 children received quinine and 156 received parenteral artemisinin therapy (artemether or artesunate). After adjustment for disease severity, artemisinin derivatives were associated with a 78% reduction in in-hospital mortality (adjusted odds ratio, 0.22; 95% CI, 0.07–0.67). Among cerebral malaria survivors, children treated with artemisinin derivatives also had reduced neurologic deficits at discharge (quinine, 41.7%; artemisinin derivatives, 23.7%, p=0.007). Over a 2-year follow-up, artemisinin derivatives as compared to quinine were associated with better adjusted scores (negative scores better) in internalizing behavior and executive function in children irrespective of the age at severe malaria episode. After adjusting for multiple comparisons, artemisinin derivatives were associated with better adjusted scores in behavior and executive function in children <6 years of age at severe malaria exposure following adjustment for child age, sex, socioeconomic status, enrichment in the home environment, and the incidence of hospitalizations over follow-up. Children receiving artesunate had the greatest reduction in mortality and benefit in behavioral outcomes and had reduced inflammation at 1-month follow-up compared to children treated with quinine. Conclusions Treatment of severe malaria with artemisinin derivatives, particularly artesunate, results in reduced in-hospital mortality and neurologic deficits in children of all ages, reduced inflammation following recovery, and better long-term behavioral outcomes. These findings suggest artesunate has long-term beneficial effects in children surviving severe malaria.

Long-term visual outcome after microsurgical removal of occipital lobe cavernomas

2012 ◽  
Vol 117 (2) ◽  
pp. 295-301 ◽  
Author(s):  
Juri Kivelev ◽  
Elina Koskela ◽  
Kirsi Setälä ◽  
Mika Niemelä ◽  
Juha Hernesniemi
Keyword(s):  
Visual Field ◽  
Visual Fields ◽  
Visual Field Loss ◽  
Occipital Lobe ◽  
Visual Outcome ◽  
Surgical Removal ◽  
Long Term Outcome ◽  
Visual Field Deficit

Object Cavernomas in the occipital lobe are relatively rare. Because of the proximity to the visual cortex and incoming subcortical tracts, microsurgical removal of occipital cavernomas may be associated with a risk of visual field defects. The goal of the study was to analyze long-term outcome after operative treatment of occipital cavernomas with special emphasis on visual outcome. Methods Of the 390 consecutive patients with cavernomas who were treated at Helsinki University Central Hospital between 1980 and 2011, 19 (5%) had occipital cavernomas. Sixteen patients (4%) were surgically treated and are included in this study. The median age was 39 years (range 3–59 years). Seven patients (56%) suffered from hemorrhage preoperatively, 5 (31%) presented with visual field deficits, 11 (69%) suffered from seizures, and 4 (25%) had multiple cavernomas. Surgery was indicated for progressive neurological deterioration. The median follow-up after surgery was 5.25 years (range 0.5–14 years). Results All patients underwent thorough neuroophthalmological assessment to determine visual outcome after surgery. Visual fields were classified as normal, mild homonymous visual field loss (not disturbing the patient, driving allowed), moderate homonymous visual field loss (disturbing the patient, driving prohibited), and severe visual field loss (total homonymous hemianopia or total homonymous quadrantanopia). At the last follow-up, 4 patients (25%) had normal visual fields, 6 (38%) had a mild visual field deficit, 1 (6%) complained of moderate visual field impairment, and 5 (31%) had severe homonymous visual field loss. Cavernomas seated deeper than 2 cm from the pial surface carried a 4.4-fold risk of postoperative visual field deficit relative to superficial ones (p = 0.034). Six (55%) of the 11 patients presenting with seizures were seizure-free postoperatively. Eleven (69%) of 16 patients had no disability during the long-term follow-up. Conclusions Surgical removal of occipital cavernomas may carry a significant risk of postoperative visual field deficit, and the risk is even higher for deeper lesions. Seizure outcome after removal of these cavernomas appeared to be worse than that after removal in other supratentorial locations. This should be taken into account during preoperative planning.

Real-world evidence of cancer immunotherapy (CIT) combination treatment in first-line (1L) extensive-stage small cell lung cancer (ES-SCLC).

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 8561-8561
Author(s):  
Eric S. Nadler ◽  
Anupama Vasudevan ◽  
Kalatu Davies ◽  
Yunfei Wang ◽  
Ann Johnson ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Real World ◽  
Performance Status ◽  
Descriptive Analysis ◽  
Patient Characteristics ◽  
Treatment Patterns ◽  
Combination Regimen ◽  
Duration Of Treatment ◽  
The Real

8561 Background: Atezolizumab plus chemotherapy was the first CIT combination regimen approved for 1L treatment of ES-SCLC in 2019. This study investigated patient characteristics and treatment patterns for patients with ES-SCLC receiving this regimen in the real-world community oncology setting. Methods: This was a retrospective study including adult patients diagnosed with ES-SCLC between 01-Oct-2018 (after IMpower 133 publication in NEJM Sep-2018) and 31-Dec-2019, with follow-up through 31-March-2020 using The US Oncology Network electronic health records data. Descriptive analyses of patient characteristics and treatment patterns were conducted, with Kaplan-Meier (K-M) methods used to assess time to treatment discontinuation (TTD) and time to next treatment/death (TTNT). Results: Of the 408 patients included in this study, 267 (71.4%) received atezo+carboplatin+etoposide (Atezo+Chemo), 80 (21.4%) received carboplatin+etoposide (Chemo only) and the rest received other regimens. The Atezo+Chemo patients in the real-world cohort compared with the IMpower 133 trial (n = 201) were older (median age 68 vs. 64 years) and included fewer males (45% vs. 64%), fewer white race (73% vs. 81%), more patients with brain metastases at baseline (23% vs. 9%), and more patients with worse ECOG (2/3) performance-status score (24% vs. 0%). The median follow-up, TTD, and TTNT in months (mo) for the real-world cohort are presented in the table alongside the best comparable measures reported for the trial. Conclusions: Most patients in this real-world ES-SCLC cohort received the Atezo+Chemo regimen in the 1L setting. While the follow-up was much shorter and patients had worse baseline characteristics (age, brain metastases, ECOG) in the real-world setting compared to the IMpower 133 trial, the real-world median TTD in this descriptive analysis was found to be in line with the median duration of treatment in the trial. Further research with longer follow-up comparing the real-world effectiveness of the CIT and chemo regimens is needed.[Table: see text]

scholarly journals Outcome in surgically treated Rathke's cleft cysts: long-term monitoring needed

2011 ◽  
Vol 165 (1) ◽  
pp. 33-37 ◽  
Author(s):  
R Trifanescu ◽  
V Stavrinides ◽  
P Plaha ◽  
S Cudlip ◽  
J V Byrne ◽  
...  
Keyword(s):  
Visual Field ◽  
Visual Field Defects ◽  
Rathke's Cleft Cysts ◽  
Long Term Monitoring ◽  
Rathke's Cleft ◽  
Term Monitoring ◽  
Field Defects ◽  
Tsh Deficiency

ObjectiveTo clarify the outcome of all cases of Rathke's cleft cysts (RCC) treated surgically and followed up in Oxford during a long-term period.Subjects and methodsThe records of all patients with RCC seen in the Department of Endocrinology between January 1978 and June 2009 were reviewed.ResultsA total of 33 patients (20 females, median age 43 years) were identified. At presentation, major visual field defects were detected in 58% of patients and gonadotrophin, ACTH and TSH deficiency in 60, 36 and 36% of patients respectively. Desmopressin treatment was required in 18% of patients. Treatment consisted of cyst evacuation combined with or without biopsy/removal of the wall. Post-operatively, visual fields improved in 83% of patients with impairment, whereas there was no reversal of ACTH or TSH deficiency or of diabetes insipidus. All but one subject had imaging follow-up during a mean period of 48 months (range 2–267). Cyst relapse was detected in 22% of patients at a mean interval of 29 months (range 3–48 months); in 57% of them, the recurrence was symptomatic. Relapse-free rates were 88% at 24-months and 52% at 48-months follow-up. At last assessment, at least quadrantanopia was reported in 19% of patients, gonadotrophin, ACTH and TSH deficiency in 50, 42 and 47% of patients respectively. Desmopressin treatment was required in 39% of patients.ConclusionsIn this study of patients with RCC and long-term follow-up, we showed a considerable relapse rate necessitating long-term monitoring. Surgical intervention is of major importance for the restoration of visual field defects, but it does not improve endocrine morbidity, which in the long-term affects a substantial number of patients.

Optical Coherent Tomography Predicts Long-Term Visual Outcome of Pituitary Adenoma Surgery: New Perspectives From a 5-Year Follow-up Study

Neurosurgery ◽  
2020 ◽  
Vol 88 (1) ◽  
pp. 106-112 ◽  
Author(s):  
Young Soo Chung ◽  
Minkyun Na ◽  
Jihwan Yoo ◽  
Woohyun Kim ◽  
In-Ho Jung ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Visual Field ◽  
Assessment Tool ◽  
Visual Fields ◽  
Visual Field Defects ◽  
Mean Deviation ◽  
Rnfl Thickness ◽  
Long Term Follow Up

Abstract BACKGROUND Compressive optic neuropathy is the most common indication for transsphenoidal surgery for pituitary adenomas. Optical coherence tomography (OCT) is a useful visual assessment tool for predicting postoperative visual field recovery. OBJECTIVE To analyze visual parameters and their association based on long-term follow-up. METHODS Only pituitary adenoma patients with abnormal visual field defects were selected. A total of 188 eyes from 113 patients assessed by visual field index (VFI) and 262 eyes from 155 patients assessed by mean deviation (MD) were enrolled in this study. Postoperative VFI, MD, and retinal nerve fiber layer (RNFL) thickness were evaluated and followed up. After classifying the patients into normal (&gt;5%) and thin (&lt;5%) RNFL groups, we investigated whether preoperative RNFL could predict visual field outcomes. We also observed how RNFL changes after surgery on a long-term basis. RESULTS Both preoperative VFI and MD had a linear proportional relationship with preoperative RNFL thickness. Sustained improvement of the visual field was observed after surgery in both groups, and the degree of improvement over time in each group was similar. RNFL thickness continued to decrease until 36 mo after surgery (80.2 ± 13.3 μm to 66.6 ± 11.9 μm) while visual field continued to improve (VFI, 61.8 ± 24.5 to 84.3 ± 15.4; MD, −12.9 ± 7.3 dB to −6.3 ± 5.9 dB). CONCLUSION Patients with thin preoperative RNFL may experience visual recovery similar to those with normal preoperative RNFL; however, the probability of normalized visual fields was not comparable. RNFL thickness showed a strong correlation with preoperative visual field defect. Long-term follow-up observation revealed a discrepancy between anatomic and functional recovery.

scholarly journals Indications and outcomes of paediatric tracheotomy: a descriptive study using a Japanese claims database

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e031816 ◽  
Author(s):  
Kayoko Mizuno ◽  
Masato Takeuchi ◽  
Yo Kishimoto ◽  
Koji Kawakami ◽  
Koichi Omori
Keyword(s):  
Descriptive Analysis ◽  
Upper Airway ◽  
Population Based ◽  
Claims Database ◽  
Mechanical Ventilation Duration ◽  
Study Population ◽  
Underlying Diseases

ObjectiveTo examine the incidence of and indications for paediatric tracheotomy to clarify the disease burden relevant to tracheotomy in a population-based context.DesignA descriptive analysis of a retrospective cohort.SettingThis study utilised a nationwide claims database in Japan constructed by JMDC (Tokyo, Japan). The database includes claims data for approximately 3.75 million insured persons (approximately 3.1% of the population of Japan) comprising mainly company employees and their family members.ParticipantsWe identified children registered to have undergone tracheotomy from 2005 to 2017 among about 1.2 million children aged 0–15 years.Main outcome measuresThe characteristics of the study population, and indications for tracheotomy, duration of hospital stay, duration of mechanical ventilation, duration of tracheotomy dependence, complications related to tracheotomy and death were assessed. When there were multiple indications, classification for a child into multiple groups was allowed.ResultsThe study included 215 children (120 males, 56%). The median age at tracheotomy was 0.8 years. The most common age at tracheotomy was less than 12 months (n=127, 59.1%). The most common indications for tracheotomy were chronic lung disease (n=79, 36.7%), followed by neuromuscular disease (n=77, 35.8%), cardiovascular disease (n=53, 24.3%), upper airway obstruction (n=43, 20%), premature birth and related conditions (n=34, 15.8%), trauma (n=16, 7.4%), prolonged ventilation due to other causes (n=12, 5.6%) and malignancy (n=9, 4.2%). The median duration of tracheotomy dependence was 17.2 months. During the follow-up period, decannulation was achieved in 84 children (39.1%), and the median time from tracheotomy to decannulation was 12.0 months.ConclusionsMost paediatric tracheotomies were performed due to chronic underlying diseases, and the mean duration of tracheotomy dependence was nearly 1-½ years. The long-term duration of tracheotomy dependence might have some impacts on patients’ physical and mental development and the quality of life.

Long-term follow-up of visual field progression after trabeculectomy in progressive normal-tension glaucoma

Ophthalmology ◽  
2002 ◽  
Vol 109 (4) ◽  
pp. 766-770 ◽  
Author(s):  
Takashi Shigeeda ◽  
Atsuo Tomidokoro ◽  
Makoto Araie ◽  
Nobuyuki Koseki ◽  
Seiichiro Yamamoto
Keyword(s):  
Visual Field ◽  
Normal Tension Glaucoma ◽  
Visual Field Progression ◽  
Long Term Follow Up

Nivolumab + ipilimumab versus platinum-doublet chemotherapy as first-line treatment for advanced non-small cell lung cancer: Three-year update from CheckMate 227 Part 1.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 9500-9500 ◽  
Author(s):  
Suresh S. Ramalingam ◽  
Tudor Eliade Ciuleanu ◽  
Adam Pluzanski ◽  
Jong-Seok Lee ◽  
Michael Schenker ◽  
...  
Keyword(s):  
Descriptive Analysis ◽  
Stage Iv ◽  
Primary Analysis ◽  
Response Status ◽  
Treatment Naïve ◽  
Report Data ◽  
Grade 3 ◽  
Clinical Trial Information

9500 Background: In the phase 3 CheckMate 227 Part 1 (NCT02477826; minimum follow-up, 29.3 mo), 1L NIVO + IPI significantly improved overall survival (OS) vs chemo in treatment-naive patients (pts) with aNSCLC and tumor PD-L1 expression ≥ 1% (primary analysis) or < 1% (pre-specified descriptive analysis). Here we report data with 3-y minimum follow-up. Methods: Pts with stage IV / recurrent NSCLC and PD-L1 ≥ 1% (n = 1189) were randomized 1:1:1 to NIVO (3 mg/kg Q2W) + IPI (1 mg/kg Q6W), NIVO (240 mg Q2W) alone, or chemo. Pts with PD-L1 < 1% (n = 550) were randomized to NIVO + IPI, NIVO (360 mg Q3W) + chemo, or chemo. Primary endpoint was OS with NIVO + IPI vs chemo in pts with PD-L1 ≥ 1%. An exploratory analysis of OS in pts by response status (CR/PR, SD, progressive disease [PD]) at 6 mo was conducted. Results: After a median follow-up of 43.1 mo (database lock, 28 Feb 2020), pts with PD-L1 ≥ 1% continued to derive OS benefit from NIVO + IPI vs chemo (HR: 0.79; 95% CI, 0.67–0.93); 3-y OS rates were 33% (NIVO + IPI), 29% (NIVO), and 22% (chemo). At 3 y, 18% of pts with PD-L1 ≥ 1% treated with NIVO + IPI remained progression-free vs 12% with NIVO and 4% with chemo; 38% of confirmed responders remained in response in the NIVO + IPI arm at 3 y vs 32% in the NIVO arm and 4% in the chemo arm. In pts with PD-L1 < 1%, OS HR for NIVO + IPI vs chemo was 0.64 (95% CI, 0.51–0.81); 3-y OS rates were 34% (NIVO + IPI), 20% (NIVO + chemo), and 15% (chemo); 13%, 8%, and 2% of pts remained progression-free; and 34%, 15%, and 0% of confirmed responders remained in response, respectively. Pts with PD-L1 ≥ 1% with either CR/PR at 6 mo had longer subsequent OS with NIVO + IPI vs chemo; pts with SD or PD at 6 mo had generally similar subsequent OS between treatments (Table); results in PD-L1 < 1% pts will be presented. Any-grade / grade 3–4 treatment-related AEs were observed in 77% / 33% of all pts treated with NIVO + IPI, and 82% / 36% with chemo. Conclusions: With 3 y minimum follow-up, NIVO + IPI continued to provide durable and long-term OS benefits vs chemo for pts in 1L aNSCLC. Pts with PD-L1 ≥ 1% who achieved CR/PR at 6 mo had marked OS benefit with NIVO + IPI vs chemo. No new safety signals were identified for NIVO + IPI. Clinical trial information: NCT02477826. [Table: see text]

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