Citations

ABSTRACT Background Intrathecal opioids are widely used for postoperative analgesia in pediatric spine surgery, but optimal dosing remains undefined. We evaluated the relationship between intrathecal hydromorphone (ITH) dose, analgesia, and adverse effects in adolescents undergoing posterior spinal fusion (PSF). Methods In this single‐center, prospective, blinded dose‐escalation study using a biased‐coin up‐down sequential allocation design, patients aged 10–17 years undergoing PSF received ITH starting at 3.5 mcg kg −1 , with dose adjustments based on analgesic response (range 2.0 to 7 mcg kg −1 with a maximum of 400 mcg). The primary outcome was maximum postoperative pain within 18 h. Secondary outcomes included pain burden (area under the curve), 24‐h systemic opioid consumption (oral morphine equivalents [OME], excluding ITH), adverse effects, supplemental diazepam use, and rescue opioid use. Associations between dose and outcomes were assessed using Spearman correlation and logistic regression. Results Twenty‐seven patients completed the study. The median ITH dose received was 5.5 mcg kg −1 (IQR, 3.5–7.0), with a median absolute dose of 370 mcg (IQR, 180–400). No significant association was observed between ITH dose and maximum pain ( r = 0.16, p = 0.41), pain burden ( r = 0.32, p = 0.10), or 24‐h OME ( r = 0.13, p = 0.52). ITH dose was not significantly associated with the time to rescue opioid (HR = 1.24; 95% CI 0.68–2.25; p = 0.485) or diazepam (HR = 1.10; 95% CI 0.72–1.71; p = 0.655). Adverse respiratory events occurred at doses > 5 mcg kg −1 without improved analgesia. Conclusions Increasing ITH dose was not associated with improved analgesia or change in supplemental opioid or diazepam use. Doses > 5 mcg kg −1 were associated with adverse respiratory effects. These findings support conservative dosing strategies and underscore the need to define the minimum effective dose in pediatric populations.

Abstract Background Biological sex and endocrine signaling influence cancer biology, immune response, and therapeutic outcomes. Recent evidence suggests that testosterone signaling may exert brain-context-dependent protective effects in glioblastoma through the hypothalamic-pituitary-adrenal axis, reduced glucocorticoid-mediated immune suppression, and altered tumor-immune interactions. We assessed whether testosterone replacement therapy (TRT) exposure was associated with survival in solid tumor central nervous system (CNS) metastases and glioblastoma (GBM, IDH-wildtype, WHO grade 4), settings in which post-diagnosis survival and TRT timing can be clinically defined. Methods We performed a retrospective Mayo Clinic cohort study of adult patients with molecularly confirmed glioblastoma and solid tumor CNS metastases confirmed from neuroimaging reports using large language model-assisted adjudication. TRT exposure was defined by testosterone-specific prescription evidence within prespecified peri-diagnostic windows. Overall survival was evaluated using propensity score-matched Cox models, 24-month administratively censored Cox models, time-dependent Cox sensitivity analyses, and 24-month restricted mean survival time. Results In the pooled solid tumor CNS metastasis cohort, TRT exposure was associated with improved overall survival after propensity score matching (HR 0.80, 95% CI 0.65–0.98, p = 0.029) and a 3.22-month improvement in 24-month restricted mean survival time. In glioblastoma, TRT exposure was similarly associated with improved overall survival after propensity score matching (HR 0.38, 95% CI 0.14-0.98, p = 0.046) and a 5.81-month improvement in 24-month restricted mean survival time. Conclusions TRT exposure was associated with improved survival in CNS metastases and glioblastoma. These hypothesis-generating findings support prospective studies incorporating TRT timing, hormone levels, corticosteroid exposure, immune correlates, and tumor-specific stratification.

ABSTRACT Objective To estimate the pooled prevalence of lymphedema among adults with mucosal head and neck cancer treated with radiation therapy. Data Sources PubMed, Embase, Scopus, and Cochrane Library. Review Methods A comprehensive literature search of PubMed, Embase, Scopus, and Cochrane Library (2000–2025) identified cohort, case series, cross‐sectional, and clinical trial studies reporting lymphedema after radiotherapy for head and neck cancer. Logit‐transformed lymphedema prevalence was pooled using a DerSimonian‐Laird random‐effects model with Hartung‐Knapp‐Sidik‐Jonkman variance correction; statistical heterogeneity was evaluated using I 2 . This review was not prospectively registered. Results A total of 26 studies ( n = 3133 patients) met inclusion criteria. The pooled prevalence of lymphedema was 49% (95% CI, 36%–62%), with considerable heterogeneity (I 2 = 94%). Subgroup analyses yielded a pooled prevalence of 37% (12%–71%) for external and 45% (31%–60%) for internal lymphedema. Among studies reporting severity‐graded data, the pooled prevalence of clinically significant (grade ≥ 2) lymphedema was 32% (14%–59%). Lymphedema definitions and assessment methods varied across the included studies, most commonly employing clinical grading. Methodological quality was mixed, reflecting the predominantly retrospective, single‐arm nature of the available evidence. Overall certainty of evidence was very low. Funnel plot inspection and Egger's test suggested small‐study effects ( p = 0.06). Conclusion Lymphedema affects nearly half of patients following radiation for head and neck cancer. These findings may support routine surveillance, early identification, and timely referral for lymphedema management within survivorship care pathways. Future prospective studies should adopt standardized definitions and outcome measures to refine risk estimates and guide prevention strategies. Level of Evidence N/A.

Abstract Background Prostate artery embolization (PAE) requires precise visualization of complex pelvic arterial anatomy and can be aided by advanced vessel navigation tools. Photon counting detector (PCD) CT provides simultaneous ultra‐high resolution and material‐specific imaging, potentially improving automatic vessel tracing workflow for procedural planning and guidance. Purpose To identify, within a PCD‐CT workflow, the reconstruction that provides the most robust and consistent automatic vessel tracing for pre‐procedural PAE planning. Methods Ten patients underwent PCD‐CT angiography of the prostate arteries in ultra‐high‐resolution mode. Four reconstruction approaches were evaluated: conventional reconstructions with (1) standard of care kernel and (2) sharper kernel (Bv64), along with (3) monoenergetic 50 keV, and (4) iodine map spectral results. Using commercial embolization guidance software, three vessels were manually traced for each patient to establish ground truth segmentation. Subsequently, automatic vessel traces were generated using identical start/end points as the ground truth. Root mean squared error (RMSE) between automatic traces and ground truth was used to quantify tracing accuracy. Results Comparing individual traces, iodine maps demonstrated consistency with median RMSE of 0.7 mm (0.4 mm interquartile range (IQR)) versus 0.7 mm (12.5 mm IQR), 1.5 mm (14.7 mm IQR), and 0.8 mm (6.7 mm IQR) for Bv56, Bv64, and 50 keV reconstructions, respectively. Iodine maps produced fewer outliers, with 13.3% of traces and 40.0% of patients having one or more traces exceeding 5 mm RMSE, compared with 26.7%–36.7% of traces and 60.0%–80.0% of patients for the other reconstructions. Conclusions Material‐specific iodine reconstructions from PCD‐CT yield more robust automatic vessel tracing for PAE planning, offering a workflow‐compatible solution requiring minimal protocol modifications.

BACKGROUND Spindle cell oncocytoma (SCO) is a rare, nonadenomatous sellar tumor that often mimics pituitary adenomas both radiographically and clinically, making diagnosis and treatment difficult. OBSERVATIONS A 67-year-old male presented with fatigue and weakness, with MRI revealing an enhancing sellar mass with suprasellar extension and laboratory findings consistent with panhypopituitarism. He underwent endoscopic endonasal resection, which revealed a fibrous, highly vascular tumor adherent to surrounding tissue, consistent with SCO on final pathological analysis. Gross-total resection (GTR) was achieved, and the patient has been monitored regularly with no signs of recurrence at 9 months postoperatively. LESSONS SCOs are an exceedingly rare entity often indistinguishable from pituitary adenomas preoperatively, yet their intraoperative hypervascularity and fibrous texture can complicate resection and predispose patients to recurrence. Accurate identification of these tumors and GTR when possible are essential to appropriate treatment. https://thejns.org/doi/10.3171/CASE26333

Abstract Background: Radical prostatectomy (RP) remains a cornerstone treatment for patients with localized prostate cancer. Previous studies have suggested that prior RP may impact clonal evolution of metastatic disease and response to subsequent systemic therapies. In this study, we sought to investigate whether a history of prior RP is associated with treatment response and survival outcomes in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with ¹⁷⁷Lu-PSMA. Methods: In a single-institution retrospective study, we identified 260 patients who underwent 177Lu-PSMA for mCRPC. Patients were categorized based on the history of prior PR into two groups; Group A (n=147) included patients with prior PR, and Group B (n=113) included patients with intact prostate. The primary outcome was prostate-specific antigen (PSA) response, defined as a ≥50% decline from baseline (PSA50). Overall survival (OS) was evaluated as a secondary outcome. Univariable and multivariable regression analyses were performed to identify factors associated with PSA50 and OS. Results : Among 260 patients, PSA50 was achieved in 55.1% of patients with prior RP compared with 34.5% of those with an intact prostate. On multivariable logistic regression, prior RP remained independently associated with greater odds of achieving PSA50 (OR 2.1, 95% CI 1.09–4.1; p=0.03), whereas de novo metastatic disease was not independently associated with PSA50 (OR 0.97, 95% CI 0.44–2.15; p=0.9). Prior RP was also associated with improved OS on multivariable Cox regression (HR 0.60, 95% CI 0.4–0.8; p=0.008). Conclusion: In our experience, Prior RP was independently associated with improved PSA response and OS among patients with mCRPC treated with ¹⁷⁷Lu-PSMA. These findings suggest that prior treatment of the primary tumor may be associated with subsequent response to PSMA-targeted radioligand therapy, although the underlying mechanisms and potential influence of treatment selection and disease biology warrant further investigation.