BACKGROUND:Postoperative stereotactic radiosurgery after resection of brain metastases is currently the standard of care. However, rates of leptomeningeal disease (LMD) after postoperative stereotactic radiosurgery have been reported to be >30%. Neoadjuvant stereotactic radiosurgery (NaSRS) has been proposed as an alternative treatment approach to decrease this risk.OBJECTIVE:To report the local control (LC) and LMD rates in patients undergoing NaSRS.METHODS:Our retrospective multicenter case series included consecutive patients planned for SRS followed by resection of intracranial lesions with a confirmed primary malignancy. Concurrent SRS alone to other intracranial lesions was permitted. Exclusion criteria included previous local treatment to that particular lesion and Eastern Cooperative Oncology Group performance status ≥3. Outcomes reported included LC, distant intracranial control (DC), overall survival, LMD, and radionecrosis (RN) rates.RESULTS:Overall, 28 patients with 29 lesions were eligible for analysis. The median follow-up was 12.8 months. The mean age was 62.5 (range 43-80) years, and 55% were Eastern Cooperative Oncology Group performance status 0 to 1. The most common primary malignancies included non-small cell lung cancer (43%) and melanoma (32%). Hypofractionated SRS was used in 62.1%. The 12-month LC and LMD rates were 91.3% and 4.0%, respectively. The 12-month RN, DC, and overall survival rates were 5.0%, 51.5%, and 60.1%, respectively.CONCLUSION:Compared with postoperative SRS, our study suggests that NaSRS leads to comparable local control with a decreased risk of LMD and RN. This is the first NaSRS series with a majority of patients treated with fractionated SRS. NaSRS is a promising approach for appropriate patients where surgical resection is a component of local therapy.

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Retroperitoneal cystic lymphangiomaLymphangioma is a rare benign tumour of the lymphatic system that usually presents in infancy. About 90% of cystic lymphangioma cases are diagnosed by the end of the second year of life. 1 The condition results from a developmental failure of the lymphatic system. 2 About 95% of cases develop in the cervical and axillary region. The remaining 5% appear in other parts of the body. Less than 1% are found in the retroperitoneal region. 3 We report the case of a 47-year-old man who presented with a retroperitoneal cystic lymphangioma that was successfully excised.The patient had suffered from on-and-off epigastric pain, decreased appetite and weight loss for 1 year. He had no history of acute or chronic pancreatitis. No abdominal mass was palpable. Oesophagogastroduodenoscopy (OGD) showed antral gastritis only. Ultrasonography (USG) and computed tomography (CT) of the abdomen showed a 5-cm cystic lesion anterior to the splenic vein at the body and tail region of pancreas ( Fig. 1). Endoscopic ultrasonography (EUS) also showed a 5-cm cystic mass with focal nodular thickening over the cystic wall at the body and tail of the pancreas. A cystic neoplasm of pancreas was suspected initially. At exploratory laparotomy, a 5-cm retroperitoneal cystic mass located posterior to the pancreatic body and tail ( Fig. 2) was discovered. The tumour was excised completely. Pathology was consistent with a retroperitoneal cystic lymphangioma. The postoperative course was uneventful. During the follow up, all the symptoms subsided.Retroperitoneal cystic lymphangiomas are very rare. They usually grow slowly. Malignant degeneration is rare also. Most patients are asymptomatic and the mass is found incidentally during investigations for unrelated clinical problems. Like most retroperitoneal masses, they become clinically significant when they grow to a size that can cause pressure or have an obstructive effect on adjacent organs, such as intestinal obstruction and obstructive uropathy. Preoperative diagnosis is always difficult. Most of them are diagnosed during laparotomy as in our case. USG and CT scan are the choices of investigation. The characteristic feature of the condition is a large tumour containing fluid with or without septa. 4 Because of the advancements made by EUS in the preoperative assessment of upper gastrointestinal tumours and pancreatic tumours, it was used for investigation in our patient. Although, in this case, it failed to diagnose the lymphangioma before the operation, it may still have an important role in the future, when more studies have been performed.For the management of lymphangioma, most authors advocate complete surgical excision, as in our case. 3 The prognosis is excellent. Other treatment modalities such as marsupialization and injection of sclerosing agents have been reported in the literature. However, poor long-term results have rendered marsupialization obsolete. 3 Injection of a sclerosing agent could induce fibrosis around the cyst which may complicate surgic...