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John H Suh

Publications and source records attributed to John H Suh.

At least 19 recordsLinked to original sources
PubMed2007

Stereotactic radiosurgery and radiation therapy for spinal tumors.

Spinal tumors constitute 15% of all CNS neoplasms. Radiation therapy can be administered for palliation of pain and spinal cord compression. However, the amount of radiation that can be administered is often limited by the tolerance of the spinal cord, especially in cases where prior radiation therapy has been given. Stereotactic radiosurgery and radiotherapy allow the delivery of a higher dose of radiation to spinal lesions, while limiting the spinal cord dose to below the tolerance level. These are technically demanding procedures and should be performed only when proper equipment and expertise are available. Data on spinal stereotactic radiosurgery and radiotherapy have emerged in recent years. This review summarizes the clinical applications of stereotactic radiosurgery and radiotherapy for spinal tumors.

Dose-Response Relationship, Radiation↗
PubMed2006

Intensity-modulated radiotherapy for pituitary adenomas: the preliminary report of the Cleveland Clinic experience.

PURPOSE: Intensity-modulated radiotherapy (IMRT) is being increasingly used for the treatment of pituitary adenomas. However, there have been few published data on the short- and long-term outcomes of this treatment. This is the initial report of the Cleveland Clinic's experience. METHODS AND MATERIALS: Between February 1998 and December 2003, 34 patients with pituitary adenomas were treated with IMRT. A retrospective chart review was conducted for data analysis. RESULTS: With a median follow-up of 42.5 months, the treatment has proven to be well tolerated, with performance status remaining stable in 90% of patients. Radiographic local control was 89%, and among patients with secretory tumors, 100% had a biochemical response. Only 1 patient required salvage surgery for progressive disease, giving a clinical progression free survival of 97%. The only patient who received more than 46 Gy experienced optic neuropathy 8 months after radiation. Smaller tumor volume significantly correlated with subjective improvements in nonvisual neurologic complaints (p = 0.03), and larger tumor volume significantly correlated with subjective worsening of visual symptoms (p = 0.05). New hormonal supplementation was required for 40% of patients. Younger patients were significantly more likely to require hormonal supplementation (p = 0.03). CONCLUSIONS: Intensity-modulated radiation therapy is a safe and effective treatment for pituitary adenomas over the short term. Longer follow-up is necessary to determine if IMRT confers any advantage with respect to either tumor control or toxicity over conventional radiation modalities.

Adenoma↗
PubMed2006

RPA classification has prognostic significance for surgically resected single brain metastasis.

PURPOSE: To retrospectively evaluate prognostic factors that correlate with overall survival among patients with a surgically resected single brain metastasis. METHODS AND MATERIALS: An Institutional Review Board-approved database of the Cleveland Clinic Brain Tumor Institute was queried for patients with a single brain metastasis treated by surgical resection between February 1984 and January 2004. The primary endpoint was overall survival from the date of surgery by the Kaplan-Meier method. RESULTS: A total of 271 patients were included. Statistically significant variables for improved survival on multivariate analysis included age <65 years, lack of extracranial metastases, control of primary tumor, histology (non-small-cell lung carcinoma), and use of stereotactic radiosurgery. The median survival for all patients was 10.2 months. Survival of patients in recursive partitioning analysis (RPA) class 1 was better (21.4 months) than those in RPA class 2 (9.0 months, p < 0.001), RPA class 3 (8.9 months, p = 0.15), or the combined group of RPA classes 2 and 3 (9.0 months, p < 0.001). Patients had a median survival of 10.6 months after documented gross total resection and 8.7 months after subtotal resection, which approached statistical significance (p = 0.07). Those who were treated with stereotactic radiosurgery had a median survival of 17.1 months, which was greater than patients who were not treated with stereotactic radiosurgery (8.9 months, p = 0.006). CONCLUSIONS: This analysis supports the prognostic significance of the RPA classification in patients with a single brain metastasis who undergo surgical resection and adjuvant therapy. RPA class 1 patients have a very favorable prognosis with a median survival of 21.4 months.

Aged↗
PubMed2006

Validation of the RTOG recursive partitioning analysis (RPA) classification for small-cell lung cancer-only brain metastases.

PURPOSE: The Radiation Therapy Oncology Group (RTOG) developed a prognostic classification based on a recursive partitioning analysis (RPA) of patient pretreatment characteristics from three completed brain metastases randomized trials. Clinical trials for patients with brain metastases generally exclude small-cell lung cancer (SCLC) cases. We hypothesize that the RPA classes are valid in the setting of SCLC brain metastases. METHODS AND MATERIALS: A retrospective review of 154 SCLC patients with brain metastases treated between April 1983 and May 2005 was performed. RPA criteria used for class assignment were Karnofsky performance status (KPS), primary tumor status (PT), presence of extracranial metastases (ED), and age. RESULTS: Median survival was 4.9 months, with 4 patients (2.6%) alive at analysis. Median follow-up was 4.7 months (range, 0.3-40.3 months). Median age was 65 (range, 42-85 years). Median KPS was 70 (range, 40-100). Number of patients with controlled PT and no ED was 20 (13%) and with ED, 27 (18%); without controlled PT and ED, 34 (22%) and with ED, 73 (47%). RPA class distribution was: Class I: 8 (5%); Class II: 96 (62%); Class III: 51 (33%). Median survivals (in months) by RPA class were: Class I: 8.6; Class II: 4.2; Class III: 2.3 (p = 0.0023). CONCLUSIONS: Survivals for SCLC-only brain metastases replicate the results from the RTOG RPA classification. These classes are therefore valid for brain metastases from SCLC, support the inclusion of SCLC patients in future brain metastases trials, and may also serve as a basis for historical comparisons.

Adult↗
PubMed2006

Five-year survivors of brain metastases: a single-institution report of 32 patients.

PURPOSE: To report on 32 patients who survived > or = 5 years from brain metastases treated at a single institution. METHODS AND MATERIALS: The records of 1288 patients diagnosed with brain metastases between 1973 and 1999 were reviewed. Patients were treated with whole-brain radiation therapy (WBRT), surgery, and/or stereotactic radiosurgery (SRS). Thirty-two (2.5%) > or = 5-year survivors were identified. Factors contributing to long-term survival were identified. RESULTS: Median survival was 9.3 years for > or = 5-year survivors. Seven of these patients lived > or = 10 years. Female gender was the only patient characteristic that correlated with better survival (p = 0.0369). When these patients were compared with < 5-year survivors, age < 65 years (p = 0.0044), control of the primary at diagnosis (p = 0.0052), no systemic disease (p = 0.0012), recursive partitioning analysis (RPA) Class 1 (p = 0.0002 with Class 2; p = 0.0022 with Class 3), and single brain metastasis (p = 0.0018) were associated with long-term survival in the univariate logistic regression model. In the multivariate model, RPA Class 1 compared with Class 2 (OR = 0.39, p = 0.0196), surgery (OR = 0.16, p < 0.0001), and SRS (OR = 0.41, p = 0.0188) were associated with long-term survival. CONCLUSIONS: For patients with good prognostic factors such as young age, good RPA characteristics and single metastasis, treatment with surgery or SRS offers the best chance for long-term survival.

Aged↗
PubMed2006

The role of 111indium-octreotide brain scintigraphy in the diagnosis of cranial, dural-based meningiomas.

OBJECTIVE: Meningiomas are common brain tumors with somatostatin receptors that bind octreotide. We report the use of (111)indium-octreotide brain scintigraphy (OBS) for the non-invasive differentiation of meningiomas from other cranial dural-based pathology. METHODS: A retrospective analysis of our experience with OBS for non-invasive identification of meningiomas was performed. Two neuroradiologists, blinded to clinical data, utilized a standardized grading scheme to define the uptake of octreotide at 6 and 24 h post-administration. The correlation between (18) F-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), magnetic resonance imaging (MRI) scans, and octreotide uptake was assessed. RESULTS: The cohort consisted of 50 patients having a mean age of 62.4 years and a median follow-up time of 24 months. Management consisted of biopsy (n = 4); resection (n = 10); observation (n = 16); radiosurgery (n = 21); and external beam radiotherapy (n = 3). OBS was correlated with MRI (n = 50); FDG-PET brain studies (n = 38); histology (n = 14), and angiography (n = 1). In cases where definitive diagnosis could be made, the sensitivity, specificity, positive and negative predictor values for OBS alone were 100; 50; 75; and 100, respectively. OBS provided false positive data in 3 patients (metastasis, chronic inflammation, lymphoma). Use of OBS with MRI to differentiate meningiomas from other lesions was highly significant (P < 0.001). FDG-PET correctly identified malignant pathology with 100% sensitivity and specificity. CONCLUSION: OBS may increase the diagnostic specificity of conventional MRI when differentiating meningioma from other dural-based pathologies, while the addition of FDG-PET differentiates benign from malignant lesions.

Adult↗
PubMed2006

Resectable brain metastases.

Brain metastases are the most common brain tumors seen in clinical practice, comprising well over half of all brain tumors. For many years, surgical resection of brain metastases was considered a form of palliative therapy only, but more recently it has been shown to have a more important role in extending survival in appropriately selected patients. Newer surgical techniques have helped to reduce the morbidity associated with tumor resection. Although randomized studies have demonstrated the need for postoperative whole-brain radiotherapy, there remains interest in the use of other surgical adjuncts to delay or eliminate the need for fractionated radiotherapy. The use of various treatment modalities, particularly image-guided surgery and stereotactic radiosurgery, allows clinicians who are focused on the treatment of brain metastases to achieve superior levels of tumor control within the brain. As a result, overall survival is much more dependent on the status of the patient's systemic disease.

Brain Neoplasms↗
PubMed2006

Whole-brain radiotherapy with or without efaproxiral for the treatment of brain metastases: Determinants of response and its prognostic value for subsequent survival.

PURPOSE: To determine the prognostic factors for radiographic response and its prognostic value for subsequent survival in patients undergoing whole-brain radiotherapy (WBRT) for brain metastases. METHODS AND MATERIALS: Five hundred fifteen eligible patients were randomized in a phase III trial evaluating WBRT and supplemental oxygen with or without efaproxiral, an allosteric modifier of hemoglobin that reduces hemoglobin oxygen-binding affinity and enhances tumor oxygenation, potentially increasing tumor radiosensitivity. Brain images were obtained at baseline and at scheduled follow-up visits after WBRT. Landmark analysis was used to assess the ability of response at selected time points to predict subsequent survival. Logistic regression was used to assess determinants of response at 3 months. RESULTS: Treatment arm, Karnofsky Performance Status, presence or absence of liver metastases, and primary site were all determinants of response at the 3-month follow-up visit, with patients in the efaproxiral arm experiencing a 67% greater odds of response at this visit (p = 0.02). Response at 3 and 6 months was a significant prognostic factor for longer subsequent survival. CONCLUSIONS: The 3-month scan is a valuable prognostic factor for subsequent survival in patients with brain metastases treated with WBRT. Patients in the efaproxiral arm had a higher response rate at 3 and 6 months than those in the control arm.

Aged↗
PubMed2006

Pre-irradiation 9-amino [20s] camptothecin (9-AC) in patients with newly diagnosed glioblastoma multiforme.

PURPOSE: To evaluate the efficacy of 9-amino [20s] camptothecin (9-AC) given before radiation therapy to patients with newly diagnosed glioblastoma multiforme (GBM). METHODS: Eligible patients had newly diagnosed GBM who had residual measurable contrast-enhancing tumor. The trial was a phase 2 trial of 9-AC at 1100 microg/m2 /24 h infused over 72 h every two weeks for up to six cycles in patients with newly diagnosed GBM before radiation therapy. RESULTS: Fourteen patients entered the study and all were evaluable. All of the patients had progressive disease by imaging criteria after at least two cycles of 9-AC (1 month). The median overall survival was 7.5 months (range 1.5-18 months). The most common adverse event was transient lymphopenia (grade 3-4). One patient developed grade 4 neutropenic fever that resolved after three days of diagnosis. CONCLUSIONS: 9-AC lacks activity against glioblastoma multiforme (GBM). Further studies looking at the efficacy of 9-AC in GBM may be futile.

Adult↗
PubMed2006

External beam radiation helps prevent heterotopic bone formation in patients with a history of heterotopic ossification.

The aim of this study was to determine if radiation prevents heterotopic ossification (HO) in HO-forming patients after total hip arthroplasty (THA) or HO excision alone. Patients with HO in the ipsilateral hip (63 treated with THA revision and 25 treated with HO excision alone) and HO in the contralateral hip (36 treated with primary THA) were termed HO-forming patients. They underwent radiation to prevent HO. After excluding patients with inadequate follow-up, 84 patients were studied to determine if radiation prevents significant HO (Brooker Grade 3-4). For patients with ipsilateral hip HO, 12.3% developed significant HO. In patients with contralateral hip HO, 10.5% developed significant HO after THA. Sixty percent who received 6 Gy in 3 fractions after excision of ipsilateral HO developed significant HO, which was higher than for all dose-fractionation schemes combined (P = .01). In contrast, patients who received 7 Gy in 1 fraction developed significant HO 13.8% of the time, which was equivalent to all dose-fractionation schemes combined (P = not significant). Radiation prevents HO in HO-forming patients.

Adult↗
PubMed2006

Role of radiation therapy and radiosurgery in the management of craniopharyngiomas.

The variable clinical presentation, relation to vital anatomic structures, and complications associated with treatment contribute to the controversies that surround the management of craniopharyngiomas. Although the results with radiation therapy and radiosurgery have been equal to or better than those obtained with aggressive surgery, considerable debate exists regarding the role of surgery alone versus limited surgery followed by radiation therapy. Based on current data, one may consider using surgery for discrete tumors that do not involve the hypothalamus and for which gross total resection would result in minimal cognitive side effects. For tumors that clearly involve the hypothalamus and associated suprasellar structures, subtotal resection followed by radiation therapy tailored for the residual disease seems to offer the best long-term control rates with acceptable morbidity.

Craniopharyngioma↗
PubMed2006

Increased expression of 5-lipoxygenase in high-grade astrocytomas.

OBJECTIVE: 5-Lipoxygenase (5-LO) oxidizes arachidonic acid into proinflammatory eicosanoids that may promote tumorigenesis. In this study, we investigated whether 5-LO is expressed in human astrocytomas and what effect its expression may have on patient outcome. METHODS: Increased 5-LO messenger ribonucleic acid and protein expression was detected by the polymerase chain reaction and antibody-based approaches, respectively, in surgical astrocytoma specimens and established glioblastoma multiforme cell lines compared with primary cell culture from the human white matter. RESULTS: Immunohistochemical analysis revealed predominantly nuclear 5-LO staining in 44 of 49 glioblastoma multiforme samples (90%), 8 of 10 (80%) anaplastic astrocytomas samples, and 3 of 13 (23%) low-grade astrocytoma samples analyzed. Double-staining experiments with anti-CD-68 (macrophage/microglial marker) and anti-5-LO antibodies suggest that both CD-68-positive and CD-68-negative tumor cells express 5-LO protein. Staining of 5-LO was significantly more frequent in high-grade than in low-grade tumors (P = 0.001). Patients whose tumors expressed 5-LO were significantly older, had lower preoperative Karnofsky performance scores and shorter survival than patients whose tumors did not express 5-LO. After adjusting for pathological diagnosis and age, respectively, neither Karnofsky performance score nor survival were significantly associated with 5-LO staining. CONCLUSION: These data indicate that 5-LO is overexpressed in high-grade astrocytomas and supports the idea that eicosanoids may play a role in tumorigenesis of these brain tumors.

Adult↗
PubMed2006

Gamma knife radiosurgery for glomus jugulare tumors: volumetric analysis in 17 patients.

OBJECTIVE: Stereotactic radiosurgery has been used increasingly for the treatment of glomus jugulare tumors. The authors report their experience treating these tumors using gamma knife radiosurgery (GKRS), documenting the clinical and radiological outcome. METHODS: A retrospective analysis identified 17 patients with glomus jugulare tumors who underwent GKRS. Besides analysis of clinical outcome, a radiological volumetric analysis was also performed after treatment. RESULTS: There were 15 women and two men (average age, 63.1 yr) with a median follow-up period of 48 months. The median radiosurgical dose to the tumor margin was 15 Gy (range, 13-18 Gy). Eight patients (47.1%) improved clinically, two (11.8%) worsened, and seven (41.2%) were unchanged. No relationship between internal auditory canal dose and hearing loss was recorded. Tinnitus and otalgia were the symptoms that responded most favorably to GKRS. No patients experienced new lower cranial nerve palsies after GKRS. Tumor volume showed a transient increase in seven patients. Analysis of tumor volume at the time of the last magnetic resonance imaging scan recorded a decrease in eight patients, an increase in four patients, and no change in five patients. CONCLUSION: GKRS is a safe, effective treatment for glomus jugulare tumors, particularly in patients with preserved glossopharyngeal and vagus nerve function, after surgical recurrence, in the elderly, and in patients with serious preexisting medical conditions. Longer follow-up periods are required to assess long-term effects.

Adult↗
PubMed2006

Local control of brain metastases by stereotactic radiosurgery in relation to dose to the tumor margin.

OBJECT: The maximal tolerated dose (MTD) for stereotactic radiosurgery (SRS) for brain tumors was established by the Radiation Therapy Oncology Group (RTOG) in protocol 90-05, which defined three dose groups based on the maximal tumor diameter. The goal in this retrospective study was to determine whether differences in doses to the margins of brain metastases affect the ability of SRS to achieve local control. METHODS: Between 1997 and 2003, 202 patients harboring 375 tumors that met study entry criteria underwent SRS for treatment of one or multiple brain metastases. The median overall follow-up duration was 10.7 months (range 3-83 months). A dose of 24 Gy to the tumor margin had a significantly lower risk of local failure than 15 or 18 Gy (p = 0.0005; hazard ratio 0.277, confidence interval [CI] 0.134-0.573), whereas the 15- and 18-Gy groups were not significantly different from each other (p = 0.82) in this regard. The 1-year local control rate was 85% (95% CI 78-92%) in tumors treated with 24 Gy, compared with 49% (CI 30-68%) in tumors treated with 18 Gy and 45% (CI 23-67%) in tumors treated with 15 Gy. Overall patient survival was independent of dose to the tumor margin. CONCLUSIONS: Use of the RTOG 90-05 dosing scheme for brain metastases is associated with a variable local control rate. Tumors larger than 2 cm are less effectively controlled than smaller lesions, which can be safely treated with 24 Gy. Prospective evaluations of the relationship between dose to the tumor margin and local control should be performed to confirm these observations.

Adult↗
PubMed2006

Results of a phase II trial of the GliaSite radiation therapy system for the treatment of newly diagnosed, resected single brain metastases.

OBJECT: The aim of this study was to evaluate the effectiveness of brachytherapy using the GliaSite Radiation Therapy System in patients with a newly diagnosed resected single brain metastasis. The primary end point of the study was local tumor control. The secondary end points included patient survival, distant brain recurrence, quality of life, and treatment toxicity. METHODS: The authors conducted a prospective multiinstitutional phase II study of GliaSite brachytherapy prescribed at a 60-Gy dose administered to a 1-cm depth after resection of a single brain metastasis. No whole-brain radiation therapy was given. Patients were assessed at 1 and 3 months after brachytherapy and every 3 months thereafter for up to 2 years. Seventy-one patients were enrolled at 13 centers. A GliaSite balloon catheter was implanted in 62 patients. Fifty-four patients received brachytherapy. The median patient age was 60 years. The most common tumor (54%) was non-small cell lung cancer. Fifty-seven percent of patients had brain metastasis only, whereas 43% had extracranial metastasis. The median final administered dose was 60 Gy. The magnetic resonance imaging--determined local control rate, based on several different methods, was 82 to 87%. Both the median patient survival time and the median duration of functional independence were 40 weeks. Among the 35 patients who died, the cause of death was neurological in 11%. Thirteen patients underwent reoperation for suspected tumor recurrence or radiation necrosis, and histological diagnoses included radiation necrosis without tumor (nine patients), radiation necrosis mixed with tumor (two patients), and tumor only (two patients). Extracranial metastasis, tumor size, and radiation necrosis were significant factors affecting patient survival. CONCLUSIONS: In patients with a resected single brain metastasis, GliaSite brachytherapy leads to a local control rate, median patient survival time, and duration of functional independence similar to those achieved with resection plus whole-brain radiation therapy.

Adult↗
PubMed2005

Phase III study of efaproxiral as an adjunct to whole-brain radiation therapy for brain metastases.

PURPOSE: To determine whether efaproxiral, an allosteric modifier of hemoglobin, improves survival in patients with brain metastases when used as an adjunct to whole-brain radiation therapy (WBRT). PATIENTS AND METHODS: Patients with brain metastases from solid tumors and a Karnofsky performance score of > or = 70 were randomly assigned to receive WBRT with supplemental oxygen and either efaproxiral at 75 or 100 mg/kg (efaproxiral arm) or no efaproxiral (control arm). The primary end point was survival. RESULTS: The study consisted of 515 eligible patients (efaproxiral arm, n = 265; control arm, n = 250). The median survival time (MST) was 5.4 months for the efaproxiral arm versus 4.4 months for the control arm (hazard ratio [HR] = 0.87; P = .16). For the subgroup of patients with non-small-cell lung cancer (NSCLC) or breast cancer, the MST was 6.0 and 4.4 months, respectively (HR = 0.82; P = .07). Cox multiple regression analysis demonstrated a significant reduction in the risk of death for the efaproxiral arm in both primary populations. Further analysis indicated that the benefit may be restricted to the subgroup of patients with breast cancer. Response rates (radiographic complete response plus partial response) improved by 7% (P = .10) and 13% (P = .01) for all patients and for NSCLC and breast cancer patients in the efaproxiral arm, respectively. The most common severe adverse event in patients treated with efaproxiral was hypoxemia, which was reversible and effectively managed with supplemental oxygen in most patients. CONCLUSION: The addition of efaproxiral, a noncytotoxic radiation sensitizer, to WBRT may improve response rates and survival in patients with brain metastases, particularly metastases from breast cancer. A confirmatory trial for breast cancer patients has been initiated.

Adult↗
PubMed2005

Use of the Radiation Therapy Oncology Group recursive partitioning analysis classification system and predictors of survival in 19 women with brain metastases from ovarian carcinoma.

BACKGROUND: Brain metastases are an uncommon complication in women with primary ovarian carcinoma; thus, little is known about whether the Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) prognostic classification system is valid in this patient population. METHODS: From September 1985 to June 2002, 19 patients with brain metastases resulting from primary ovarian carcinoma underwent treatment at the Cleveland Clinic Foundation. The medical records of these patients were retrospectively reviewed. RESULTS: At the time of data analysis, all 19 women had died. The median age at diagnosis of primary ovarian carcinoma and brain metastasis was 51 and 54 years of age, respectively. Fifteen patients presented with a Karnofsky performance status (KPS) of 70 or higher. Seven patients had a single brain lesion and 12 had multiple lesions. All RTOG RPA prognostic classes were represented, with median survivals of 24.7, 8.9, and 2.6 months for Classes I, II, and III, respectively (P = 0.31). Patients who underwent surgical resection survived longer than those who did not (33.7 vs. 7.4 mos). The presence of multiple lesions was adversely related to survival on multivariate analysis (P = 0.03). Primary control was an important predictor of survival on multivariate analysis as well (P = 0.01) and was achieved in 15 of the 19 women. CONCLUSIONS: This is the first study to support the prognostic usefulness of the RTOG RPA classification for ovarian carcinoma patients with metastasis to the brain. The number of metastatic intracranial lesions should be included when determining the prognosis.

Adult↗