Gamma Knife surgery is effective for metastatic brain tumors from RCC. The disappearance rate of tumors is relatively low, but growth control is high. The delivered dose to the tumor margin is significantly correlated with the control of peritumoral edema. Gamma Knife surgery should be used as the initial treatment modality, if possible, even in patients with multiple metastases. Repeated GKS is recommended for newly developed brain metastases because of the low sensitivity of RCC to conventional radiation therapy.

GKS for brain stem metastases using a marginal dose of 15 Gy or less is effective and relatively safe. Accurate targeting of the tumour and safe dose planning are essential to obtain satisfactory results with GKS for brain stem metastases.

ObjectThe combination approach of Ommaya reservoir placement and Gamma Knife surgery (GKS) was evaluated for the treatment of large cystic metastatic brain tumors.MethodsThe medical records of 22 patients harboring 28 tumors, who underwent Ommaya reservoir placement followed by GKS for large cystic metastatic brain tumors were retrospectively reviewed. The patients' ages ranged 26 to 77 years (mean 57.1 years). The most common locations of primary malignancy were the breast (11 patients) followed by the lung (seven patients). The mean maximum diameter of the tumor was 40.1 mm before Ommaya reservoir placement and 31.2 mm at GKS (mean reduction of 19.9%). The mean calculated tumor volume at GKS was 13.4 cm3. The mean tumor margin dose was 16 Gy in 17 patients treated by GKS only and 11 Gy in five patients treated using both GKS and external radiotherapy. The mean follow-up period was 11.5 months. Nineteen (67.9%) of the 28 tumors were controlled. The median patient survival time was 7 months. Asymptomatic intracystic hemorrhage associated with Ommaya reservoir placement was seen in two patients with four tumors, but no serious complication occurred.Conclusions Ommaya reservoir placement followed by GKS is relatively effective and safe for large cystic metastatic brain tumors. Gamma Knife surgery should be performed within a few days of Ommaya reservoir placement. Reaccumulation and high viscosity of cystic content must be considered.

Repeated radiosurgery for brain metastases is effective and relatively long survival can be expected in some patients associated with a low risk of radiation-induced injury.

Background: The purpose of this study was to clarify the appropriate use of unfractionated heparin as an anticoagulation agent after digital replantation. Methods: This study was a prospective, randomized, single-blind, blinded-endpoint method, three-arm, parallel-group, controlled clinical trial conducted at a single institution. A total of 88 patients (101 fingers) following digital amputation and subsequent repair by anastomosis of both arteries and veins were randomly allocated into three groups: (1) control group (no heparin dose), (2) low-dose heparin group (10,000 IU/day), and (3) high-dose heparin group (start at 15,000 IU/day, then adjust the dose to achieve an activated partial thromboplastin time of 1.5 to 2.5 times the baseline). The outcomes were assessed regarding the proportion of success at 2 weeks after replantation of amputated digits, total or partial necrosis, and occurrence of complications. Results: No significant differences were found among the three groups, except for complications of congestion. The odds ratio of the heparin group compared with the control group for a success proportion was 5.40 (95 percent CI, 0.85 to 34.20; p = 0.027) in subjects aged 50 years or older. Significant elevations of activated partial thromboplastin time, aspartate transaminase, and alanine aminotransferase occurred in high-dose heparin groups on day 7. Conclusion: Unfractionated heparin administration is considered effective for patients aged 50 years or older, although the routine use of unfractionated heparin is not necessary after digital replantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.