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We recently cared for a patient with a distal ventriculoperitoneal shunt malfunction. The peritoneal catheter was coiled in a scarred pseudocyst, and we encountered strong resistance while attempting to remove the distal shunt catheter. The catheter was successfully removed under laparoscopic guidance and was found to be tightly coiled in a constrictive knot. We describe a technique for managing this unusual presentation to minimize the risk of complications., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Brain metastasis (BM) from bone and soft tissue sarcomas (STS) is very rare and mostly predicts dismal prognosis. Owing to its' rarity, data on optimal therapy including surgical management, chemotherapy, and radiotherapy is scarce. We sought to assess the prevalence, disease characteristics, and outcomes of BM in bone and STS patients treated at a single institution., Methods: A retrospective chart review was performed for consecutive bone and STS patients treated at King Hussein Cancer Center from 2007 to 2020. Patients with BM were identified. Survival was estimated by the Kaplan-Meier method. Factors of possible effect on OS was examined in univariate analysis. Survival comparisons were carried out by the log-rank test., Results: A total of 1,548 bone and STS patients were treated at our center during the eligibility period. We identified 18 patients (1.1%) who had BM at initial presentation (n = 16, 1.0%) or during follow up (n = 2; 0.1%). Fourteen patients (77.8%) were male. The median age was 29.5 years (range: 0.1-60 years). The primary tumor was most commonly located in the extremities (61%). Ten different histopathological subtypes were encountered; Ewing sarcoma (ES) was the most common (n = 4; 28%). Twelve patients (67%) had lung metastasis as the first site of metastatic disease. BM was detected at a median time of 12 months following sarcoma diagnosis (range: 1-71 months). A total of 10 patients (56%) had solitary metastasis and 4 patients (22.2%) had hemorrhagic metastasis. The most common location of brain metastatic lesions was the occipital lobe (n = 4; 22.2%). Thirteen patients received treatment for metastatic brain sarcoma. The most common treatment modality was radiotherapy, received by a total of 10 patients (55.5%), followed by surgical intervention performed in a total of 5 patients (27.7%), The other treatment modalities included combined chemo-radiotherapy (n = 2), targeted therapy plus chemotherapy, and targeted therapy plus radiotherapy (n = 1, each). At a median follow up of 10 months following detection of BM, the median OS was 4.0 months; (95% CI: 2.54-5.46). We did not identify any factor that influenced OS in univariate analysis., Conclusion: Sarcoma BM is exceedingly rare and herald's dismal prognosis. ES was a major histological subtype accounting for BM metastasis in our series., (Copyright © 2023 Copyright: © 2023 Journal of Cancer Research and Therapeutics.)

Competing Interests: There are no conflicts of interest.

Steroids are often utilized to manage patients with non-small cell lung cancer brain metastases (NSCLCBM). Steroids and elevated neutrophil-to-lymphocyte ratio (NLR) have been associated with decreased overall survival (OS) in patients treated with immune checkpoint inhibitors (ICI). We retrospectively investigated patients treated with ICI after the diagnosis of NSCLCBM at a single tertiary care institution examing the impact of steroids and NLR. Overall survival (OS) and intracranial progression-free survival (PFS) were analyzed. 171 patients treated with ICI for NSCLCBM were included. Thirty-six received steroids within 30 days of the start of ICI, and 53 patients had an NLR ≥ 5 before the start of ICI. Upfront steroids was associated with decreased OS on multivariable analysis (median OS 10.5 vs. 17.9 months, p = .03) and intracranial PFS (5.0 vs. 8.7 months, p = .045). NLR ≥ 5 was indicative of worse OS (10.5 vs. 18.4 months, p = .04) but not intracranial PFS (7.2 vs. 7.7 months, p = .61). When NLR and upfront steroids are modeled together, there is a strong interaction (p = .0008) indicating that the impact of steroids depended on the patient's NLR. In a subgroup analysis, only in patients with NLR < 4 was there a significant difference in OS with upfront steroids (26.1 vs. 15.6 months, p = .032). The impact of steroids on the efficacy of ICI in patients with NSCLCBM is dependent on the patient's NLR underscoring its importance in these patients. Patients with a low NLR, steroid use decreases the efficacy of ICI. These results can inform clinicians about the impact of steroids in patients treated with ICI.

Objective: To evaluate the role of apparent diffusion coefficient (ADC) in differentiating radiation necrosis (RN) from recurrent tumor after Gamma Knife radiosurgery (GKRS) for brain metastases (BMs)., Methods: Forty-one patients with BM who underwent surgical intervention after GKRS at Cleveland Clinic (2006-2017) were included in this retrospective study. The ADC values of the growing lesions and the contralateral hemisphere were calculated using picture archiving and communication system. These values were correlated to the percentage of RN identified on pathologic evaluation of the surgical specimen., Results: The median age of the patients was 59 years (range, 25-86 years), and lung cancer (63.4%) was the most common malignancy. Median initial (pre-GKRS) target volume of the lesions was 5.4 cc (range, 0.135-45.6 cc), and median GKRS dose was 18.0 Gy. Surgical resection or biopsy was performed at a median of 176 days after GKRS. Two variables were statistically significant predictors of predominate RN (75%-100%) in the surgical specimen: 1) ADC of the lesion on the preresection magnetic resonance imaging (MRI) and 2) initial pre-GKRS target volume. ADC >1.5 × 10 -3 mm 2 /s within the lesion on MRI predicted significant RN on pathologic evaluation of the lesion (P < 0.05). Similarly, when the target volume before GKRS was large (>10 cc), the risk of identifying significant necrosis in the pathologic specimen was elevated (P < 0.05)., Conclusions: Our data suggest that the combination of lesion ADC on MRI prior to surgical intervention and the initial target volume can predict RN with reasonable accuracy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Most research on sedentary lifestyle has focused on pain and disability, while neuromuscular outcomes (postural control and strength) have received less attention. The objective of the study was to determine whether low level of physical activity is negatively associated with measures of lower body muscular strength and postural control in individuals with and without non-specific chronic low back pain (NSCLBP).Twenty-four subjects with NSCLBP (28.8 ± 5.9 years) and 24 age, gender, and body mass index matched healthy controls participated in the study. Subjects were sub-classified into 4 subgroups based on their physical activity level: Non-active NSCLBP; Active NSCLBP; Non-active healthy control; and Active healthy control. Each subgroup consisted of 12 subjects. Peak force of hip muscles strength was assessed using a handheld dynamometer. Postural control was assessed using computerized posturography and the Y Balance Test.There was no significant group by physical activity interaction for strength and static and dynamic postural control, except for static control during left single leg stance with eyes closed (P = .029). However, there was a significant difference in strength and postural control by physical activity (P < .05). Postural control and peak force of hip muscles strength were significantly associated with physical activity (r ranged from 0.50 to 0.66, P < .001 and r ranged from 0.40 to 0.59, P < .05, respectively).Postural control and hip strength were independently related to physical activity behavior. A sedentary behavior may be an important risk factor for impaired postural control and hip muscles strength, and that physical fitness is vital to neuromuscular outcomes.

OBJECTIVEGamma Knife radiosurgery (GKRS) has been successfully used for the treatment of intracranial meningiomas given its steep dose gradients and high-dose conformality. However, treatment of skull base meningiomas (SBMs) may pose significant risk to adjacent radiation-sensitive structures such as the cranial nerves. Fractionated GKRS (fGKRS) may decrease this risk, but until recently it has not been practical with traditional pin-based systems. This study reports the authors' experience in treating SBMs with fGKRS, using a relocatable, noninvasive immobilization system.METHODSThe authors performed a retrospective review of all patients who underwent fGKRS for SBMs between 2013 and 2018 delivered using the Extend relocatable frame system or the Icon system. Patient demographics, pre- and post-GKRS tumor characteristics, perilesional edema, prior treatment details, and clinical symptoms were evaluated. Volumetric analysis of pre-GKRS, post-GKRS, and subsequent follow-up visits was performed.RESULTSTwenty-five patients met inclusion criteria. Nineteen patients were treated with the Icon system, and 6 patients were treated with the Extend system. The mean pre-fGKRS tumor volume was 7.62 cm3 (range 4.57-13.07 cm3). The median margin dose was 25 Gy delivered in 4 (8%) or 5 (92%) fractions. The median follow-up time was 12.4 months (range 4.7-17.4 months). Two patients (9%) experienced new-onset cranial neuropathy at the first follow-up. The mean postoperative tumor volume reduction was 15.9% with 6 patients (27%) experiencing improvement of cranial neuropathy at the first follow-up. Median first follow-up scans were obtained at 3.4 months (range 2.8-4.3 months). Three patients (12%) developed asymptomatic, mild perilesional edema by the first follow-up, which remained stable subsequently.CONCLUSIONSfGKRS with relocatable, noninvasive immobilization systems is well tolerated in patients with SBMs and demonstrated satisfactory tumor control as well as limited radiation toxicity. Future prospective studies with long-term follow-up and comparison to single-session GKRS or fractionated stereotactic radiotherapy are necessary to validate these findings and determine the efficacy of this approach in the management of SBMs.