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The role of surgery in the treatment of metastatic spinal tumors causing epidural compression traditionally consisted of posterior decompression. This procedure plus radiotherapy, however, could not be demonstrated to provide any benefit over radiotherapy alone, and surgery fell into disfavor in managing metastatic vertebral tumors. The advent of newer, more sophisticated approaches, along with improved spinal instrumentation and reconstruction techniques, which allowed direct decompression of neural elements and resection of the tumor, have revived the use of surgery in these tumors. These modern spinal surgery techniques, in combination with radiotherapy, have yielded significantly superior functional outcomes and prolonged survival in symptomatic metastatic epidural compression when compared to radiotherapy alone. Management of spinal metastases is evolving, and a multitude of factors determine the indication for and the technique and goals of surgical intervention. Between 1993 and 2005, 21.1% of patients with metastatic spinal tumors evaluated at The University of Texas M.D. Anderson Cancer Center were treated surgically by the Department of Neurosurgery. The most common spinal metastasis operated upon was metastatic kidney cancer (31.5%), even though kidney cancer was only the third most common primary tumor (after lung and breast cancers) giving rise to vertebral metastases observed during the same time period at this institution. This highlights the importance of the histology of the primary cancer (among other factors) in determining the indication for surgical intervention.

Background: The authors compared the patterns of failure in patients with intracranial germinoma who were managed with either chemotherapy and focal irradiation or with craniospinal irradiation (CSI)., Methods: A retrospective review was conducted on 21 patients with intracranial germinoma and treated with radiotherapy (RT) to the central nervous system at The University of Texas M. D. Anderson Cancer Center from 1981 to 2002. The study group was comprised of 13 males and 8 females with a median age at diagnosis of 19 years. Nine patients received chemotherapy prior to focal RT. Twelve patients received CSI., Results: The actuarial 10-year survival rate for all patients was 86%. The overall survival rate at 10 years was 89% for patients who received focal RT and 83% for patients who received CSI (P = .73). The 10-year local control rate in the brain for patients who received focal irradiation was 59% compared with 100% for patients who received CSI (P = .08). The rate of distant control in the spine at 5 years was 62% for patients who received focal irradiation and 100% for patients who received CSI (P = .04)., Conclusions: Although focal techniques of irradiation with chemotherapy are attractive methods that limited the volume irradiated, the strategy appeared to be associated with increased rates of failures in the brain and spine., ((c) 2006 American Cancer Society.)

Background: Neoplastic meningitis (NM) occurs in 5-10% of patients with malignant disease. Little is known about the outcomes of patients with gastrointestinal (GI) malignancies who develop NM. For this report, the authors characterized the clinical course and attempted to identify prognostic factors in patients with NM due to primary malignancies of the GI tract., Methods: In this retrospective study, 21 patients with GI primary tumors and NM were identified: Their medical records and imaging studies were reviewed., Results: The patient population was composed of patients with gastric adenocarcinoma (n = 8 patients), esophageal adenocarcinoma (n = 7 patients), colon and/or rectal adenocarcinoma (n = 5 patients), and pancreatic adenocarcinoma (n = 1 patient). The median overall survival after the initial diagnosis of adenocarcinoma was 55 weeks (range, 8-884 wks), and the median survival after the diagnosis of NM was 7 weeks (range, 0-64 wks). Four patients died during palliative radiotherapy. No factors identified had an impact on outcome, including symptoms, physical findings at diagnosis, imaging characteristics, or cerebrospinal fluid findings. Univariate analysis showed a trend toward better outcomes for patients who received any kind of treatment directed toward the NM., Conclusions: Patients with NM from GI tract adenocarcinomas universally had poor outcomes. Until NM can be diagnosed earlier and/or until more effective therapies are identified, comfort care alone may be a reasonable alternative for some of these unfortunate patients.

Between January 1975 and April 2001, 8,225 patients with ovarian cancer were seen at The University of Texas M.D. Anderson Cancer Center. Brain metastases developed in 72 of these patients (0.9%). The medical records of these patients were reviewed to assess the incidence of these metastases and their correlates of survival, as well as to describe the various treatment modalities used against them and their respective outcomes. The mean age of patients at the time of brain metastasis diagnosis was 53.7 years. The median interval between the diagnosis of the primary cancer and brain metastasis was 1.84 years. Neurological deficit, headache, and seizure were the most common symptoms. The brain was the only site of metastasis in 43% of patients. Multiple metastases were seen in 65% of them, although this may be a slight underestimate, as brain metastases in 17% of patients were evaluated prior to the magnetic resonance imaging era. The median survival time after the diagnosis of brain metastases was 6.27 months (95% CI, 4.48-8.06 months). The combination of surgical resection and whole-brain radiation therapy (WBRT) resulted in a longer survival time (median, 23.07 months) than did WBRT alone (median, 5.33 months) or surgery alone (median, 6.90 months) (p < 0.01 in both instances, multivariate Cox proportional hazards model analysis). The prognosis for patients with brain metastases from ovarian cancer appears to be poor. The existence of systemic dissemination at the time of brain metastasis was associated with a worse survival trend. The only significant predictor of survival in our series was the treatment modality. In particular, the resection of brain metastasis from ovarian cancer followed by WBRT appeared to be superior to resection alone or WBRT alone.

Objective and Importance: Gliomatosis cerebri (GC) is a rare type of primary brain tumor that diffusely infiltrates more than two lobes of the brain while the normal cerebral architecture is maintained. To the best of our knowledge, the association between an acquired tonsillar herniation and GC has never been reported. In this article, we describe three patients with progressive gliomatosis of the cerebellar hemispheres who subsequently showed signs and symptoms secondary to tonsillar herniation. Early recognition of this potentially life-threatening complication allowed us to recommend prompt surgical intervention., Clinical Presentation: One patient with primary, or Type I, GC presented with suboccipital headaches, and two patients with secondary, or Type II, GC presented with the signs and symptoms of progressive myelopathy. Serial imaging studies demonstrated progressive involvement of the cerebellum, descent of the cerebellar tonsils through the foramen magnum, and cervicomedullary spinal cord compression., Intervention: Once the tonsillar herniation was recognized, all three patients underwent posterior fossa decompression, a cervical laminectomy to the lowest level of the tonsillar herniation, and duraplasty. All three patients experienced immediate improvement in their conditions., Conclusion: Early recognition of tonsillar herniation, a possibly overlooked cause of death in patients with GC, allows for early surgical intervention as a potentially lifesaving procedure and significant improvement in the patient's condition.