임상 : Leksell Gamma Knife Perfexion과 Model C의 치료계획 효용성 비교 : 임상연구

김정재 ( Jung Jae Kim ),김기홍 ( Gi Hong Kim ),박용구 ( Yong Gou Park ),장종희 ( Jong Hee Chang ) 대한뇌종양학회 2012 대한뇌종양학회지 Vol.11 No.2

Objective:The purpose of this study was to compare the dose planning between the Leksell Gamma Knife Perfexion (LGK PFX) and the Leksell Gamma Knife C (LGK C) using variable indices. Methods:A total of 100 cases, which were composed of 35 meningiomas, 20 vestibular schwannomas, 35 metastases, and 10 pituitary adenomas, were enrolled in this study. First, these cases were treated with the LGK PFX and then, were re-planned with the LGK C. We compared these two models in terms of the number of shots, the percentage of coverage, the conformity index (CI), Paddick’s conformity index (PCI), the gradient index (GI), and the beam on time. Results:The LGK PFX completely outperformed the LGK C in terms of GI and the LGK PFX tended to have a longer beam on time than that of the LGK C. However, in patients with schwannomas, the LGK PFX outperformed the LGK C in terms of the CI, PCI, and GI, and in patients with pituitary adenomas, the LGK PFX outperformed the LGK C in terms of the percentage of coverage, PCI, and GI with statistical significance. Conclusion:The LGK PFX is an entirely redesigned radiosurgery unit accompanied by the development of software. The LGK PFX is supposed to achieve highly conformal dose prescription consisting of many isocenters with a reasonable treatment time.

Leksell Gamma Knife Perfexion과 Model C의 치료계획 효용성 비교 : 임상연구

김정재 ( Jung Jae Kim ),김기홍 ( Gi Hong Kim ),박용구 ( Yong Gou Park ),장종희 ( Jong Hee Chang ) 대한뇌종양학회 대한신경종양학회 2014 Brain Tumor Research and Treatment Vol.2 No.1

Objective:The purpose of this study was to compare the dose planning between the Leksell Gamma Knife Perfexion (LGK PFX) and the Leksell Gamma Knife C (LGK C) using variable indices. Methods:A total of 100 cases, which were composed of 35 meningiomas, 20 vestibular schwannomas, 35 metastases, and 10 pituitary adenomas, were enrolled in this study. First, these cases were treated with the LGK PFX and then, were replanned with the LGK C. We compared these two models in terms of the number of shots, the percentage of coverage, the conformity index (CI), Paddick`s conformity index (PCI), the gradient index (GI), and the beam on time. Results:The LGK PFX completely outperformed the LGK C in terms of GI and the LGK PFX tended to have a longer beam on time than that of the LGK C. However, in patients with schwannomas, the LGK PFX outperformed the LGK C in terms of the CI, PCI, and GI, and in patients with pituitary adenomas, the LGK PFX outperformed the LGK C in terms of the percentage of coverage, PCI, and GI with statistical significance. Conclusion:The LGK PFX is an entirely redesigned radiosurgery unit accompanied by the development of software. The LGK PFX is supposed to achieve highly conformal dose prescription consisting of many isocenters with a reasonable treatment time.

반복된 뇌실질 출혈로 진단이 늦어진 시상부 신경교모세포종

김병우(Byeong Woo Kim),심유식(Yu Shik Shim),장종희(Jong Hee Chang),안정용(Jung Yong Ahn) 대한두개저학회 2008 대한두개저학회지 Vol.3 No.1

Although rare, neoplasms can be obstructed by intracerebral hemorrhage, delaying histological diagnosis and proper treatment. We report the case of a 30-year-old male presenting with serial intracerebral hemorrhages in the left thalamus. Stereotactic biopsy failed to make histologic diagnosis; open biopsy, two months after the initial hemorrhage, diagnosed glioblastoma. The characteristics of hemorrhage from glioblastoma drawn from our experience and a comprehensive review of the literature include the following: (1) under 14 years of age or old age (2) deep seated supratentorial or posterior fossa location (3) disproportionately diffuse brain edema (4) suspiciously enhancing mass lesion (5) irregular shape and heterogeneous appearance with solid areas of blood, multiple hemorrhage, and a ring-shaped hemorrhage. Direct proof of hemorrhagic origin is necessary for diagnosis and treatment of intracerebral hemorrhage with atypical location, imaging findings, or clinical course.

임상적 비기능성 뇌하수체 종양의 미세현미경적 가성피막의 제거

김병우(Byeong Woo Kim),심유식(Yu Shik Shim),장종희(Jong Hee Chang),안정용(Jung Yong Ahn),김선호(Sun Ho Kim) 대한두개저학회 2008 대한두개저학회지 Vol.3 No.1

Objective : The aim of this study was to investigate the precise histological characteristics of the boundary, using surgical specimens from patients who underwent intensive resection of “microsurgical pseudocapsule”of clinically non-functioning pituitary tumors (CNPTs). Furthermore, we compared the remission rate of CNPTs between subjects with (Group 1) and without (Group 2) intensive resection of microsurgical pseudocapsule in order to correlate the histological complete resection and endocrinological remission. Patients and Methods : Between January 2000 and December 2007, 113 patients underwent intensive microsurgical dissection during the transsphenoidal surgery in one hospital (Group 1). In the other hand, 24 patients underwent conventional subcapsular resection without intentionally removing the microsurgical pseudocapsule in another hospital (Group 2). Results : The overall surgical remission rate in Group 1 with intensive resection of microsurgical pseudocapsule were statistically higher than the rates in Group 2 (without intensive resection of microsurgical pseudocapsule) (p=0.032). However, there were no statistical differences in postoperative hormonal function change between Group 1 and 2. Conclusions : Our results indicate that aggressive resection of psuedocapsules increases the cure rate without aggravating pituitary function.

3차원 입체조형치료에 의한 아교모세포종의 방사선 선량증가 연구

조재호(Jae Ho Cho),이창걸(Chang Geol Lee) 김경주(Kyoung Ju Kim),박진호(Jino Bak),이세병(Se Byeoung Lee),조삼주(Sam Ju Cho),심수정(Su Jung Shim),윤덕현(Dok Hyun Yoon),장종희(Jong Hee Chang),김태곤(Tae Gon Kim),김동석(Dong Suk Kim),서장옥 대한방사선종양학회 2004 Radiation Oncology Journal Vol.22 No.4

목 적: 아교모세포종의 방사선치료에서 국소제어율과 생존율을 향상시켜 보고자 3차원 입체조형치료기법을 이용 한 방사선선량 증가 연구를 전향적으로 시행하였다. 대상 및 방법: 1997년 1월부터 2002년 7월까지 아교모세포종으로 조직학적 진단이 되고 전신수행도(KPS)가 60 이상으로 수술 후 방사선치료를 받은 환자를 대상으로 하였다. 프로토콜에 따라 전향적으로 연구에 참여한 42예의 고선량군과 후향적 대조군인 33예의 저선량군을 비교 분석하였다. 고선량군은 3차원 입체조형치료법에 의해 63.0∼70.2 Gy (중앙값 66 Gy)의 고선량 방사선을 조사받았으며, 저선량군은 2차원 치료방식으로 현재 표준선량으로 여겨지고 있는 59.4 Gy 정도(최소선량 50.4 Gy, 중앙선량 59.4 Gy)의 계획된 방사선치료를 종료할 수 있었던 환자들을 대상으로 하였다. 수술절제범위에 따라 나누어보면 전절제술 30예(40%), 준전절제술 30예(40%), 부분절제술 8예(11%), 그리고 조직생검만 시행된 환자가 7예(9%)였다. 각 환자의 육안종양체적은 CT 혹은 MRI상 수술절제연 및 잔류종양에 의해 정의되었다. 종양주변 부종은 저선량군에서는 임상표적체적에 포함되었지만, 고선량군에서는 재발양상 및 선량증가에 따른 합병증 증가의 가능성을 고려하여 제외하였다. 환자의 전체 및 무진행생존기간은 수 술 받은 날을 기준으로 Kaplan-Meier법으로 산출하였고, 기존 문헌에 보고되고 있는 예후인자들과 각 환자에 조사 된 방사선 선량, 표적체적 등이 생존율에 미치는 영향을 Log rank test 및 Cox regression analysis로 분석하였다. 추 적관찰을 위해 정기적으로 MRI가 시행되었다. 결 과: 전체환자의 중앙 생존기간 및 무진행 생존기간은 각각 15±1.65, 11±0.95개월이었다. 중앙생존기간은 저선량군 및 고선량군이 각각 14±0.94개월, 21±5.03개월로 고선량군에서 보다 나은 치료성적을 보여주었으며, 중앙무진행생존기간은 저선량군 10±1.63개월, 고선량군 12±1.59개월이었다. 특히 2년 생존율에 있어서 고선량군은 44.7%로 19.2%인 저선량군에 비해 훨씬 좋은 예후를 보였다. 단변량분석에서 예후에 영향을 미치는 중요인자로는 환자의 나이, 전신수행도, 종양의 위치, 수술절제범위, 표적체적, 방사선총선량 등이었다. 다변량분석에서 통계적으로 유의한 인자는 환자의 나이(p=0.012), 수술절제범위(p=0.000), 방사선선량군(p=0.049)이었다. 방사선괴사와 같은 방사선으로 인한 직접적인 만성합병증은 추적관찰기간 동안 발생하지 않았다. 결 론: 3차원 입체조형치료기법을 통하여 70 Gy까지의 방사선을 부작용 없이 조사할 수 있었고, 근치적 국소요법의 일환으로 방사선 선량증가가 전체 생존기간 및 무진행 생존기간을 향상시킬 수 있을 것으로 기대한다. Purpose: To investigate the effects of radiation dose-escalation on the treatment outcome, complications and the other prognostic variables for glioblastoma patients treated with 3D-conformal radiotherapy (3D-CRT). Materials and Methods: Between Jan 1997 and July 2002, a total of 75 patients with histologically proven diagnosis of glioblastoma were analyzed. The patients who had a Karnofsky Performance Score (KPS) of 60 or higher, and received at least 50 Gy of radiation to the tumor bed were eligible. All the patients were divided into two arms; Arm 1, the high-dose group was enrolled prospectively, and Arm 2, the low-dose group served as a retrospective control. Arm 1 patients received 63∼70 Gy (Median 66 Gy, fraction size 1.8∼2 Gy) with 3D-conformal radiotherapy, and Arm 2 received 59.4 Gy or less (Median 59.4 Gy, fraction size 1.8 Gy) with 2D-conventional radiotherapy. The Gross Tumor Volume (GTV) was defined by the surgical margin and the residual gross tumor on a contrast enhanced MRI. Surrounding edema was not included in the Clinical Target Volume (CTV) in Arm 1, so as to reduce the risk of late radiation associated complications; whereas as in Arm 2 it was included. The overall survival and progression free survival times were calculated from the date of surgery using the Kaplan-Meier method. The time to progression was measured with serial neurologic examinations and MRI or CT scans after RT completion. Acute and late toxicities were evaluated using the Radiation Therapy Oncology Group neurotoxicity scores. Results: During the relatively short follow up period of 14 months, the median overall survival and progression free survival times were 15±1.65 and 11±0.95 months, respectively. There was a significantly longer survivaltime for the Arm 1 patients compared to those in Arm 2 (p=0.028). For Arm 1 patients, the median survival and progression free survival times were 21±5.03 and 12±1.59 months, respectively, while for Arm 2 patients they were 14±0.94 and 10±1.63 months, respectively. Especially in terms of the 2-year survival rate, the high-dose group showed a much better survival time than the low-dose group; 44.7% versus 19.2%. Upon univariate analyses, age, performance status, location of tumor, extent of surgery, tumor volume and radiation dose group were significant factors for survival. Multivariate analyses confirmed that the impact of radiation dose on survival was independent of age, performance status, extent of surgery and target volume. During the follow-up period, complications related directly with radiation, such as radionecrosis, has not been identified. Conclusion: Using 3D-conformal radiotherapy, which is able to reduce the radiation dose to normal tissues compared to 2D-conventional treatment, up to 70 Gy of radiation could be delivered to the GTV without significant toxicity. As an approach to intensify local treatment, the radiation dose escalation through 3D-CRT can be expected to increase the overall and progression free survival times for patients with glioblastomas.

임상 : 크기가 큰 전상돌기 수막종의 수술적 치료

노태훈 ( Tae Hoon Roh ),홍창기 ( Chang Ki Hong ),김창현 ( Chang Hyun Kim ),안정용 ( Jung Yong Ahn ),장종희 ( Jong Hee Chang ),이규성 ( Kyu Sung Lee ) 대한뇌종양학회 2009 대한뇌종양학회지 Vol.8 No.2

Objective:Clinoidal meningiomas represent a surgical challenge. The purpose of this study was to analyze our clinical experience with clinoidal meningiomas. Methods:A retrospective analysis was performed on data obtained in 23 consecutive patients with large clinoidal meningiomas who underwent surgical resection at our hospital between August 1999 and June 2008. All patients underwent surgery through the pterional approach with zygomatic osteotomy. A skull base approach with combined extra- and intradural anterior clinoidectomy was used in 8. The follow-up period ranged from 14 to 120 months(56.3±8.8 months). Results:The mean tumor size was 4.82(±1.62) cm. A gross total resection was accomplished in all patients. Seven patients( 30.4%) had giant tumor(largest diameter>6 cm). Nineteen patients(82.6%) had a good outcome, one had a mild hemiparesis because of postoperative epidural hematoma, but she was fully recovered after the physical rehabilitation. Three patients(13.0%) developed third nerve palsy after surgical removal. One(4.3%) of the 23 tumors recurred during follow-up and was retreated with surgery. Twelve patients(52.2%) had significant visual deficits preoperatively, and the majority of the patients experienced significant visual improvement. Conclusion:The primary goals of surgery are to achieve aggressive tumor removal with avoidance of morbidity and mortality. With the use of the skull base technique, total resection and excellent visual outcome may be achieved with minimal morbidity in most patients with clinoidal meningiomas.

임상 : 대후두공과 상위경추신경 전방으로의 극외측경과접근법; 수술술기와 22예의 임상분석

문주형 ( Ju Hyung Moon ),홍창기 ( Chang Ki Hong ),김창현 ( Chang Hyun Kim ),안정용 ( Jung Yong Ahn ),장종희 ( Jong Hee Chang ),이규성 ( Kyu Sung Lee ) 대한뇌종양학회 2009 대한뇌종양학회지 Vol.8 No.2

Objective:Because diseases that are situated anterior to the foramen magnum, lower clivus, and the upper cervical spinal canal permit only limited access, they are considered some of the most difficult intracranial lesions to surgically treat. The far-lateral transcondylar approach provides such a route. The author has reviewed the technique as well as the surgical results here. Methods:During a 6-year period 22 patients underwent surgery in which far-lateral approach were performed. This approach to the craniocervical junction was utilized in patients with aneurysm, schwannoma, meningioma, and chordoma affecting the cervicomedullary junction. Medical records, including imaging studies, descriptions of microsurgical findings, photographs, and video records of operative procedures, were reviewed. Mean follow up period was 4.4 years. Results:Total tumor resection was achieved in 16 patients, and a subtotal resection of the tumor was performed in the other 4 patients. In the 2 patients with vertebral artery-posterior inferior cerebellar artery(PICA) aneurysms, 1 underwent clipping, the other underwent trapping and occipital artery-PICA bypass procedure. Postoperative complications included CSF leak in 4 and temporary low cranial nerve dysfunction in 4. There was no significant postoperative complication in the remainder of the patients, and their conditions improved after surgery. Conclusion:Successful surgical management of anterior foramen magnum lesion depends on precise understanding of their unique microsurgical anatomy, avoidance of pitfalls, and the surgeon`s experience. Sufficient exposure, minimal brain retraction, and preservation of the lower cranial nerves are necessary for a safe surgery.

임상 : 악성 뇌종양에서 Gliadel® Wafer의 효용성; 예비 보고

심규원 ( Kyu Won Shim ),박영석 ( Young Seok Park ),김정희 ( Jong Hee Chang ),장종희 ( Jung Hee Kim ),최중언 ( Joong Uhn Choi ),김동석 ( Dong Seok Kim ) 대한뇌종양학회 2007 대한뇌종양학회지 Vol.6 No.2

Introduction:Adjuvant systemic chemotherapy increases survival for malignant glioma patients. However, it is unable to effectively cross the blood-brain barrier and have unacceptable systemic toxicities, and the short exposure time of tumor tissue to chemotherapeutic agents. Consequently, many researchers have tried to develop innovative local treatments that bypass the blood-brain barrier and allow for direct treatment in the central nervous system(interstitial chemotherapy). Recently, Gliadel® wafer containing carmustine(BCNU) was approved for the interstitial chemotherapy. We present our initial experience in using interstitial chemotherapy as a strategy to treat malignant brain tumors. Materials and Methods:We analyzed the clinical feature, MRI figures, KPS score, and progression-free survival in 13 malignant brain tumor patients treated with interstitial chemotherapy using Gliadel® wafer from Sep 2004 to Dec 2006. There were 6 glioblastomas, 4 anaplastic astrocytomas, and 3 poorly differentiated carcinomas. Each patient has different treatment histories before and after insertion of Gliadel® wafer. Out of 3 metastatic brain tumors, 2 were recurred after gamma knife surgery. Old patient with huge cystic metastatic tumor refused other kind of chemotherapy. So we inserted Gliadel® wafer after grossly total removal of tumor without any other treatment. Three anaplastic astrocytomas and three glioblastomas recurred after surgery or biopsy, followed by concomitant radiation and Temodal chemotherapy. Three glioblastomas and one anaplastic astrocytoma were treated with interstitial chemotherapy using Gliadel® wafer at the first surgery followed by concomitant radiation and Temodal® chemotherapy. Results:There was not any complication related to interstitial chemotherapy using Gliadel® wafer during follow-up (follow up duration:mean - 10 months, range -3~20 months). Three patients were dead 8, 11 and 12 months after after insertion of Gliadel® wafer(2 anaplastic astrocytomas and 1 glioblastoma). Follow-up MRI of 2 glioblastoma patients revealed tumor regrowth 3 and 19 months after insertion of Gliadel® wafer. The others are alive. The survivals showed the good performance status. Conclusion:This would be the brief preliminary report about the local control of the highly infiltrative brain tumor. Because the local progression or recurrence is still problematic combination of interstitial chemotherapy using Gliadel® wafer and systemic chemotherapy with Temodal® or other anticancer agents could improve patient`s survival without increasing additional systemic toxicity.

임상 : 뇌종양 환자에서 관류강조 자기공명영상의 유용성 및 한계점

장원석 ( Won Suk Chang ),강정한 ( Jeong Han Kang ),조진모 ( Jin Mo Cho ),김진아 ( Jin Na Kim ),김응엽 ( Eung Yeop Kim ),안정용 ( Jung Yong Ahn ),김동석 ( Dong Seok Kim ),장종희 ( Jong Hee Chang ) 대한뇌종양학회 2009 대한뇌종양학회지 Vol.8 No.1

Introduction:Accurate diagnosis and grading of brain tumors are critical to determine the specific treatment planning and prognosis of each tumor type. Evaluation of tumor status during treatment to assess therapeutic response and treatmentrelated complications is also important. Recent developments in the field of magnetic resonance imaging(MRI) have been adopted with varying success in the management of brain tumors. We studied the usefulness and limitation of perfusion MRI, one of new MRI techniques, in patients with a brain tumor. Materials and Methods:We analyzed 100 perfusion MR images in 72 patients who treated between December 2005 to August 2006. The type of lesions was glioma in 62 patients, lymphoma in 11, metastasis in 6, other tumor in 7, and nontumorous lesion in 14. The perfusion MR images were obtained by 3.0T MRI using dynamic contrast enhanced method. We calculated relative cerebral blood volume(rCBV) with dedicated software program. Results:The mean rCBV of high grade gliomas(WHO grade III-IV) was significantly higher than that of astrocytic low grade gliomas(WHO grade II). Additionally, rCBV of glioma and tumor grading showed positive linear correlation. However, the value of rCBV is not correlated with the tumor grade in glioma with oligodendroglioma component. While there was no statistically significant difference of rCBV between low grade gliomas, and lymphomas or metastatic brain tumors, the rCBV of high grade gliomas was higher than that of lymphomas or metastatic brain tumors. The perfusion MRI was also helpful for distinguishing recurrence of high grade gliomas from radiation necrosis, and the rCBV was higher in recurrent cases. Conclusion:Even though perfusion MRI has several limitations such as susceptibility artifact, low resolution, the possibility of errors during interpretation, no absolute diagnostic values, and less effectiveness in hypervascular benign tumors or oligodendroglial tumors, this new MRI technique could be a useful method for preoperative diagnosis of brain mass lesion and assessing the results of treatment.