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Bin-Alamer O, Alnefaie N, Qedair J, Chaudhary A, Hallak H, Abdulbaki A, Mallela AN, Palmisciano P, Gersey ZC, Legarreta AD, Labib MA, Zada G, Sheehan JP, Couldwell WT, Lunsford LD, Abou-Al-Shaar H. Single session versus multisession stereotactic radiosurgery for the management of intracranial meningiomas: a systematic review and meta-analysis. J Neurooncol 2023; 161:215-224. [PMID: 35976546 DOI: 10.1007/s11060-022-04112-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/03/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To compare the efficacy, outcomes, and complications of single session (SS-SRS) and multisession (MS-SRS) stereotactic radiosurgery in the treatment of intracranial meningiomas. METHODS Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane. A systematic review and meta-analysis of treatment protocols and outcomes were conducted. After the selection process, 20 articles describing 1483 cases were included. RESULTS A total of 1303 patients who underwent SS-SRS and 180 patients who underwent MS-SRS for the management of their intracranial meningioma were reported in the included studies. SS-SRS and MS-SRS had comparable one-year (SS-SRS: 98% vs. MS-SRS: 100%, p > 0.99) and five-year (SS-SRS: 94% vs. MS-SRS: 93%, p = 0.71) tumor control rates. The groups also had comparable tumor volume reduction/tumor regression rates (SS-SRS: 44% vs. MS-SRS: 25%, p = 0.25), tumor volume stability rates (SS-SRS: 51% vs. MS-SRS: 75%, p = 0.12), and tumor progression rates (SS-SRS: 4% vs. MS-SRS: 4%, p = 0.89). SS-SRS and MS-SRS yielded similar complication rates (10.4% vs. 11.4%, p = 0.68) and comparable functional improvement rates (MS-SRS: 44% vs. SS-SRS: 36%, p = 0.57). However, MS-SRS was used for significantly larger tumor volumes (MS-SRS: 23.8 cm3 vs. SS-SRS: 6.1 cm3, p = 0.02). CONCLUSION SS-SRS and MS-SRS resulted in comparable tumor control, tumor volumetric change, and functional outcomes despite significant biases in selecting patients for SS- or MS-SRS.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nada Alnefaie
- Department of Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Jumanah Qedair
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Adhiraj Chaudhary
- Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Hana Hallak
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohamed A Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Karras CL, Texakalidis P, Nie JZ, Trybula SJ, Youngblood MW, Sachdev S, Thomas TO, Kalapurakal J, Chandler JP, Magill ST. Outcomes following stereotactic radiosurgery for foramen magnum meningiomas: a single-center experience and systematic review of the literature. Neurosurg Focus 2022; 53:E6. [DOI: 10.3171/2022.8.focus22299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/19/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE
Foramen magnum meningiomas (FMMs) pose a unique challenge given their intimate anatomical relationship with the craniovertebral junction. While resection has been studied extensively, much less has been reported about the use of stereotactic radiosurgery (SRS) for FMMs. This study includes what is to the authors’ knowledge the first systematic review in the literature that summarizes patient and treatment characteristics and synthesizes outcomes following SRS for FMMs.
METHODS
A retrospective chart review was conducted at a single major academic institution, and a systematic review was performed according to PRISMA guidelines. The initial search on the PubMed and Scopus databases yielded 530 results. Key data extracted from both databases included Karnofsky Performance Status (KPS) score and neurological deficits at presentation, tumor location, treatment indication, target volume, single versus multiple fractions, marginal and maximum doses, isodose line, clinical and radiographic follow-up times, and primary (clinical stability and local control at last follow-up) and secondary (mortality, adverse radiation events, time to regression, progression-free survival) outcomes.
RESULTS
The study patients included 9 patients from the authors’ institution and 165 patients across 4 studies who received SRS for FMMs. The weighted median age at treatment was 60.2 years, and 73.9% of patients were female. Common presenting symptoms included headache (33.9%), dizziness/ataxia (29.7%), cranial nerve deficit(s) (27.9%), numbness (22.4%), weakness (15.2%), and hydrocephalus (4.2%). Lateral/ventrolateral (64.2%) was the most common tumor location. SRS was utilized as the primary therapy in 63.6% of patients and as salvage (21.8%) or adjuvant (14.5%) therapy for the rest of the patients. Most patients (91.5%) were treated with a single fraction. A tumor with a weighted median target volume of 2.9 cm3 was treated with a weighted median marginal dose, maximum dose, and isodose line of 12.9 Gy, 22.8 Gy, and 58%, respectively. Clinical stability and local control at last follow-up were achieved in 98.8% and 97.0% of patients, respectively. Only one possible adverse radiation event occurred, and no mortality directly related to the tumor or SRS was reported.
CONCLUSIONS
In this retrospective analysis and systematic review, the authors demonstrate SRS to be an effective and safe treatment option for carefully selected patients with FMMs.
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Affiliation(s)
| | | | - Jeffrey Z. Nie
- School of Medicine, Southern Illinois University, Springfield; and
| | - S. Joy Trybula
- Department of Neurological Surgery, Northwestern University, Chicago
| | | | - Sean Sachdev
- Department of Radiation Oncology, Northwestern University, Chicago, Illinois
| | - Tarita O. Thomas
- Department of Radiation Oncology, Northwestern University, Chicago, Illinois
| | - John Kalapurakal
- Department of Radiation Oncology, Northwestern University, Chicago, Illinois
| | - James P. Chandler
- Department of Neurological Surgery, Northwestern University, Chicago
| | - Stephen T. Magill
- Department of Neurological Surgery, Northwestern University, Chicago
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3
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Ruiz-Garcia H, Trifiletti DM, Mohammed N, Hung YC, Xu Z, Chytka T, Liscak R, Tripathi M, Arsanious D, Cifarelli CP, Caceres MP, Mathieu D, Speckter H, Mehta GU, Lekovic GP, Sheehan JP. Skull Base Meningiomas in Patients with Neurofibromatosis Type 2: An International Multicenter Study Evaluating Stereotactic Radiosurgery. Skull Base Surg 2022; 83:e173-e180. [PMID: 35832959 DOI: 10.1055/s-0041-1722937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Objective Meningiomas are the second most common tumors in neurofibromatosis type 2 (NF-2). Microsurgery is challenging in NF-2 patients presenting with skull base meningiomas due to the intrinsic risks and need for multiple interventions over time. We analyzed treatment outcomes and complications after primary Gamma Knife radiosurgery (GKRS) to delineate its role in the management of these tumors. Methods An international multicenter retrospective study approved by the International Radiosurgery Research Foundation was performed. NF-2 patients with at least one growing and/or symptomatic skull base meningioma and 6-month follow-up after primary GKRS were included. Clinical and radiosurgical parameters were recorded for analysis. Results In total, 22 NF-2 patients with 54 skull base meningiomas receiving GKRS as primary treatment met inclusion criteria. Median age at GKRS was 38 years (10-79 years). Most lesions were located in the posterior fossa (55.6%). Actuarial progression free survival (PFS) rates were 98.1% at 2 years and 90.0% at 5 and 10 years. The median follow-up time after initial GKRS was 5.0 years (0.6-25.5 years). Tumor volume at GKRS was a predictor of tumor control. Lesions >5.5 cc presented higher chances to progress after radiosurgery ( p = 0.043). Three patients (13.64%) developed adverse radiation effects. No malignant transformation or death due to meningioma or radiosurgery was reported. Conclusions GKRS is effective and safe in the management of skull base meningiomas in NF-2 patients. Tumor volume deserve greater relevance during clinical decision-making regarding the most appropriate time to treat. GKRS offers a minimally invasive approach of particular interest in this specific group of patients.
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Affiliation(s)
- Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Nasser Mohammed
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
| | - Tomas Chytka
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Manjul Tripathi
- Department of Neurological Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David Arsanious
- Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia, United States
| | - Christopher P Cifarelli
- Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia, United States
| | - Marco Perez Caceres
- Department of Neurological Surgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - David Mathieu
- Department of Neurological Surgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - Herwin Speckter
- Department of Neurological Surgery, Dominican Gamma Knife Center and CEDIMAT Hospital, Santo Domingo, Dominican Republic
| | - Gautam U Mehta
- Department of Neurological Surgery, House Ear Institute, Los Angeles, California, United States
| | - Gregory P Lekovic
- Department of Neurological Surgery, House Ear Institute, Los Angeles, California, United States
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
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4
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Multimodal treatment strategy for clinoidal meningioma: Superficial temporal artery-middle cerebral artery bypass as a safe short- and long-term strategy. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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5
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Ius T, Tel A, Minniti G, Somma T, Solari D, Longhi M, De Bonis P, Scerrati A, Caccese M, Barresi V, Fiorentino A, Gorgoglione L, Lombardi G, Robiony M. Advances in Multidisciplinary Management of Skull Base Meningiomas. Cancers (Basel) 2021; 13:2664. [PMID: 34071391 PMCID: PMC8198762 DOI: 10.3390/cancers13112664] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 12/18/2022] Open
Abstract
The surgical management of Skull Base Meningiomas (SBMs) has radically changed over the last two decades. Extensive surgery for patients with SBMs represents the mainstream treatment; however, it is often challenging due to narrow surgical corridors and proximity to critical neurovascular structures. Novel surgical technologies, including three-dimensional (3D) preoperative imaging, neuromonitoring, and surgical instruments, have gradually facilitated the surgical resectability of SBMs, reducing postoperative morbidity. Total removal is not always feasible considering a risky tumor location and invasion of surrounding structures and brain parenchyma. In recent years, the use of primary or adjuvant stereotactic radiosurgery (SRS) has progressively increased due to its safety and efficacy in the control of grade I and II meningiomas, especially for small to moderate size lesions. Patients with WHO grade SBMs receiving subtotal surgery can be monitored over time with surveillance imaging. Postoperative management remains highly controversial for grade II meningiomas, and depends on the presence of residual disease, with optional upfront adjuvant radiation therapy or close surveillance imaging in cases with total resection. Adjuvant radiation is strongly recommended in patients with grade III tumors. Although the currently available chemotherapy or targeted therapies available have a low efficacy, the molecular profiling of SBMs has shown genetic alterations that could be potentially targeted with novel tailored treatments. This multidisciplinary review provides an update on the advances in surgical technology, postoperative management and molecular profile of SBMs.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy
| | - Alessandro Tel
- Maxillofacial Surgery Department, Department of Medicine, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.T.); (M.R.)
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy;
- IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, 80125 Naples, Italy; (T.S.); (D.S.)
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, 80125 Naples, Italy; (T.S.); (D.S.)
| | - Michele Longhi
- Unit of Radiosurgery and Stereotactic Neurosurgery, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata (AOUI), 37128 Verona, Italy;
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant’ Anna University Hospital, 44124 Ferrara, Italy; (P.D.B.); (A.S.)
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44124 Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant’ Anna University Hospital, 44124 Ferrara, Italy; (P.D.B.); (A.S.)
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44124 Ferrara, Italy
| | - Mario Caccese
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy; (M.C.); (G.L.)
| | - Valeria Barresi
- Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy;
| | - Alba Fiorentino
- Radiation Oncology Department, Advance Radiation Therapy, General Regional Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy;
| | - Leonardo Gorgoglione
- Department of Neurosurgery, Hospital “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy;
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy; (M.C.); (G.L.)
| | - Massimo Robiony
- Maxillofacial Surgery Department, Department of Medicine, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.T.); (M.R.)
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6
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Marchetti M, Sahgal A, De Salles AAF, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan J, Suh JH, Yomo S, Fariselli L. Stereotactic Radiosurgery for Intracranial Noncavernous Sinus Benign Meningioma: International Stereotactic Radiosurgery Society Systematic Review, Meta-Analysis and Practice Guideline. Neurosurgery 2021; 87:879-890. [PMID: 32463867 PMCID: PMC7566438 DOI: 10.1093/neuros/nyaa169] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 03/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) for benign intracranial meningiomas is an established treatment. OBJECTIVE To summarize the literature and provide evidence-based practice guidelines on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS Articles in English specific to SRS for benign intracranial meningioma, published from January 1964 to April 2018, were systematically reviewed. Three electronic databases, PubMed, EMBASE, and the Cochrane Central Register, were searched. RESULTS Out of the 2844 studies identified, 305 had a full text evaluation and 27 studies met the criteria to be included in this analysis. All but one were retrospective studies. The 10-yr local control (LC) rate ranged from 71% to 100%. The 10-yr progression-free-survival rate ranged from 55% to 97%. The prescription dose ranged typically between 12 and 15 Gy, delivered in a single fraction. Toxicity rate was generally low. CONCLUSION The current literature supporting SRS for benign intracranial meningioma lacks level I and II evidence. However, when summarizing the large number of level III studies, it is clear that SRS can be recommended as an effective evidence-based treatment option (recommendation level II) for grade 1 meningioma.
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Affiliation(s)
- Marcello Marchetti
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italia
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- Medical Physics Ltd, Queen Square Radiosurgery Centre, London, United Kingdom
| | - Bruce E Pollock
- Department of Radiation Oncology and Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Jean Regis
- Stereotactic and Functional Neurosurgery Service and Gamma Knife Unit CHU Timone, Marseille, France
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italia
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7
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Snyder KC, Cunningham J, Huang Y, Zhao B, Dolan J, Wen N, Chetty IJ, Shah MM, Siddiqui SM. Dosimetric Evaluation of Fractionated Stereotactic Radiation Therapy for Skull Base Meningiomas Using HyperArc and Multicriteria Optimization. Adv Radiat Oncol 2021; 6:100663. [PMID: 33997481 PMCID: PMC8099749 DOI: 10.1016/j.adro.2021.100663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/07/2021] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Treatment planning of skull based meningiomas can be difficult due to the irregular shaped target volumes and proximity to critical optic structures. This study evaluated the use of HyperArc (HA) radiosurgery optimization and delivery in conjunction with multicriteria optimization (MCO) to create conformal and efficient treatment plans for conventionally fractionated radiation therapy to difficult base-of-skull (BOS) lesions. Methods and Materials Twelve patients with BOS meningioma were retrospectively planned with HA-specific optimization algorithm, stereotactic normal tissue objective (SRS-NTO), and conventional automatic normal tissue objective to evaluate normal brain sparing (mean dose and V20 Gy). MCO was used on both SRS-NTO and automatic normal tissue objective plans to further decrease organ-at-risk doses and target dose maximum to within clinically acceptable constraints. Delivery efficiency was evaluated based on planned monitor units. Results The SRS-NTO in HA can be used to improve the mid- and low-dose spread to normal brain tissue in the irradiation of BOS meningiomas. Improvement in normal brain sparing can be seen in larger, more irregular shaped lesions and less so in smaller spherical targets. MCO can be used in conjunction with the SRS-NTO to reduce target dose maximum and dose to organ at risk without sacrificing the gain in normal brain sparing. Conclusions HA can be beneficial both in treatment planning by using the SRS-NTO and in delivery efficiency through the decrease in monitor units and automated delivery.
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Affiliation(s)
- Karen Chin Snyder
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Justine Cunningham
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Yimei Huang
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Bo Zhao
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Jennifer Dolan
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Mira M Shah
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
| | - Salim M Siddiqui
- Department of Radiation Oncology, Henry Ford Health Systems, Detroit, Michigan
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8
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Yu Z, Huang B, Liang R. Radiation-induced cavernous malformation after stereotactic radiosurgery for cavernous sinus meningioma: a case report. BMC Neurol 2020; 20:422. [PMID: 33218314 PMCID: PMC7678286 DOI: 10.1186/s12883-020-01995-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 11/09/2020] [Indexed: 01/24/2023] Open
Abstract
Background Radiation-induced cavernous malformation (RICM) is a rare sequela of stereotactic radiosurgery (SRS) treatment of intracranial tumors. To date, no study reported on RICM after SRS for meningiomas originating from the skull base. The relationship between locus of initial meningioma and RICM has not been studied. Case presentation A 57-year-old woman presented with persistent headaches and blepharoptosis at initial episode. MRI disclosed a right parasellar lesion, diagnosed as a cavernous sinus meningioma (CSM). After receiving a single-fractionated SRS, headache relieved, but blepharoptosis did not significantly improve. Three years and three months later, she returned with headaches and dizziness. MRI showed an enlarged CSM. Moreover, a new mass-like lesion, suspected hemangioma, appeared in the nearby right temporal lobe. After surgical removal of the new lesion and the CSM, the patient’s neurological symptoms significantly improved. Pathology confirmed CSM and temporal RICM. Conclusions We report the first rare case of RICM occurring after SRS for CSM. The RICM may be in the same region as the initial tumor. Surgical intervention was preferred for symptomatic RICM and initial meningioma. We recommend long-term regular followup MRIs for patients with meningioma after SRS treatment.
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Affiliation(s)
- Zuan Yu
- Department of Neurosurgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Bin Huang
- Department of Neurosurgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Risheng Liang
- Department of Neurosurgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China.
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9
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Lippitz BE, Bartek J, Mathiesen T, Förander P. Ten-year follow-up after Gamma Knife radiosurgery of meningioma and review of the literature. Acta Neurochir (Wien) 2020; 162:2183-2196. [PMID: 32591948 PMCID: PMC7415024 DOI: 10.1007/s00701-020-04350-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 04/14/2020] [Indexed: 02/03/2023]
Abstract
Objectives With regard to the generally slow growth of meningioma, it is essential to analyse clinical treatment results in a long-term perspective. The purpose of the present analysis is to provide clinical data after Gamma Knife radiosurgery of meningioma in a 10-year perspective together with a review of the current literature. Methods The current study is a retrospective analysis of 86 consecutive Swedish patients with meningiomas treated using Gamma Knife radiosurgery at the Karolinska Hospital Stockholm between March 1991 and May 2001. A total of 130 tumours were treated in 115 treatment sessions. The median radiological follow-up was 10 years (1.8–16.5 years), and the median clinical follow-up was 9.4 years (2.1–17.4 years). Results After a median follow-up period of 10 years, local tumour control was achieved in 87.8% of meningiomas (108/123 tumours). The median latency between initial treatment and local (in-field) recurrence (n = 15) was 5.8 years (1.9–11.5). Recurrences adjacent but outside the initial radiation field occurred in 15.1% of patients (13/86) at a median of 7.5 years (1.3–15.7). New meningiomas were seen in 10.5% after a median of 5.4 years (0.9–10.8). In 72% of patients, no further treatment was required, 17.4% (15/86) underwent a second Gamma Knife treatment, 4.7% (4/86) required later open surgery and 5.8% (5/86) required both secondary treatments. Eighty-six percent of patients were neurologically unchanged or improved. A significantly lower rate of local (in-field) recurrences was seen in meningiomas treated with a prescription dose of > 13.4 Gy (7.1% vs. 24%, p = 0.02). Conclusions The current retrospective analysis provides a 10-year follow-up and comprises one of the longest available follow-up studies of radiosurgically treated meningiomas. The current series documents a persistent high local tumour control after Gamma Knife treatment, while providing an estimation of a necessary minimum dose for long-term tumour control in meningiomas. The study confirms the validity of previous short-term data in a long-term perspective.
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Affiliation(s)
- Bodo E Lippitz
- Interdisciplinary Centre for Radiosurgery (ICERA), Radiological Alliance Hamburg, Mörkenstr.47, 22767, Hamburg, Germany.
- Department of Clinical Neuroscience, Karolinska Institute, Centre for Molecular Medicine L8:04, Karolinska University Hospital, S-17176, Stockholm, Sweden.
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska Hospital, S-17176, Stockholm, Sweden
- Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Tiit Mathiesen
- Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej3, 2200, Copenhagen, Denmark
- Department of Neurosurgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Petter Förander
- Department of Neurosurgery, Karolinska Hospital, S-17176, Stockholm, Sweden
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Patibandla MR, Lee CC, Tata A, Addagada GC, Sheehan JP. Stereotactic radiosurgery for WHO grade I posterior fossa meningiomas: long-term outcomes with volumetric evaluation. J Neurosurg 2019; 129:1249-1259. [PMID: 29303453 DOI: 10.3171/2017.6.jns17993] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEResearch over the past 2 decades has been characterizing the role of stereotactic radiosurgery (SRS) in the treatment of benign intracranial tumors, including meningiomas. However, few studies have examined the long-term outcomes of SRS treatment for posterior fossa meningiomas (PFMs). Furthermore, previous studies have typically used single diameter measurements when reporting outcomes, which can yield misleading results. The authors describe the use of SRS in the treatment of benign WHO grade I PFMs and correlate volumetric analysis with long-term outcomes.METHODSThis study is a retrospective analysis of a prospectively maintained IRB-approved database. Inclusion criteria were a diagnosis of WHO grade I PFM with subsequent treatment via single-session SRS and a minimum of 3 follow-up MRI studies available. Volumetric analysis was performed on the radiosurgical scan and each subsequently available follow-up scan by using slice-by-slice area calculations of the meningioma and numerical integration with the trapezoid rule.RESULTSThe final cohort consisted of 120 patients, 76.6% (92) of whom were female, with a median age of 61 years (12-88 years). Stereotactic radiosurgery was the primary treatment for 65% (78) of the patients, whereas 28.3% (34) had 1 resection before SRS treatment and 6.7% (8) had 2 or more resections before SRS. One patient had prior radiotherapy. Tumor characteristics included a median volume of 4.0 cm3 (0.4-40.9 cm3) at treatment with a median margin dose of 15 Gy (8-20 Gy). The median clinical and imaging follow-ups were 79.5 (15-224) and 72 (6-213) months, respectively. For patients treated with a margin dose ≥ 16 Gy, actuarial progression-free survival rates during the period 2-10 years post-SRS were 100%. In patients treated with a margin dose of 13-15 Gy, the actuarial progression-free survival rates at 2, 4, 6, 8, and 10 years were 97.5%, 97.5%, 93.4%, 93.4%, and 93.4%, respectively. Those who were treated with ≤ 12 Gy had actuarial progression-free survival rates of 95.8%, 82.9%, 73.2%, 56.9%, and 56.9% at 2, 4, 6, 8, and 10 years, respectively. The overall tumor control rate was 89.2% (107 patients). Post-SRS improvement in neurological symptoms occurred in 23.3% (28 patients), whereas symptoms were stable in 70.8% (85 patients) and worsened in 5.8% (7 patients). Volumetric analysis demonstrated that a change in tumor volume at 3 years after SRS reliably predicted a volumetric change and tumor control at 5 years (R2 = 0.756) with a p < 0.001 and at 10 years (R2 = 0.421) with a p = 0.001. The authors also noted that the 1- to 5-year tumor response is predictive of the 5- to 10-year tumor response (R2 = 0.636, p < 0.001).CONCLUSIONSStereotactic radiosurgery, as an either upfront or adjuvant treatment, is a durable therapeutic option for WHO grade I PFMs, with high tumor control and a low incidence of post-SRS neurological deficits compared with those obtained using alternate treatment modalities. Lesion volumetric response at the short-term follow-up of 3 years is predictive of the long-term response at 5 and 10 years.
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Affiliation(s)
- Mohana Rao Patibandla
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 2Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan; and
| | - Athreya Tata
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Ito S, Saegusa T, Ozawa Y, Higuchi Y, Iwadate Y, Serizawa T, Nagano O, Kageyama Y, Yamakami I. Function-Preserving Multimodal Treatment for Jugular Foramen Meningiomas. J Neurol Surg B Skull Base 2019; 80:239-243. [PMID: 31143565 DOI: 10.1055/s-0038-1668137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/30/2018] [Indexed: 10/28/2022] Open
Abstract
Objectives Despite being pathologically benign, jugular foramen meningioma (JFM) may be locally aggressive and spread in three compartments. Because of the complex anatomical location, radical removal of JFM usually causes serious morbidity through lower cranial nerve (LCN) deficits. To accomplish long-standing tumor control with good functional outcomes, we report function-preserving multimodal treatment (FMT) for JFM, comprising the combination of intradural tumor removal with the preservation of LCN function and stereotactic radiosurgery (RS) for the residual tumor. Materials This study investigated six JFM patients (five women, one man). Preoperatively, five patients showed no LCN sign. Results All patients underwent function-preserving retrosigmoid intradural tumor removal, and no patient developed new LCN deficit. Three patients underwent RS for the residual tumor at 8 to 12 months after surgery. After RS, all three tumors were controlled. No patients showed tumor recurrence or new LCN deficits in the follow-up period (2 months to 8 years). Conclusion FMT for JFMs can accomplish long-standing tumor control with excellent functional outcomes.
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Affiliation(s)
- Seiro Ito
- Department of Neurosurgery, Chiba Rosai Hospital, Ichihara City, Chiba, Japan
| | - Takashi Saegusa
- Department of Neurosurgery, Chiba Rosai Hospital, Ichihara City, Chiba, Japan
| | - Yoshinori Ozawa
- Department of Neurosurgery, Chiba Rosai Hospital, Ichihara City, Chiba, Japan
| | - Yoshinori Higuchi
- Department of Neurosurgery, Chiba University Graduate School of Medicine, Chiba City, Chiba, Japan
| | - Yasuo Iwadate
- Department of Neurosurgery, Chiba University Graduate School of Medicine, Chiba City, Chiba, Japan
| | - Toru Serizawa
- Department of Neurosurgery, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Osamu Nagano
- Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Yusuke Kageyama
- Department of Neurosurgery, Seikei-kai Chiba Medical Center, Chiba, Japan
| | - Iwao Yamakami
- Department of Neurosurgery, Seikei-kai Chiba Medical Center, Chiba, Japan
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12
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Multisession radiosurgery for perioptic meningiomas: medium-to-long term results from a CyberKnife cooperative study. J Neurooncol 2019; 143:597-604. [PMID: 31119480 DOI: 10.1007/s11060-019-03196-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Most recent literature has confirmed the efficacy of single-session radiosurgery (sRS) in the treatment of intracranial meningioma. Unfortunately, sRS is not always applicable due to large tumor volume and the proximity of the tumor to critical structures. When sRS is not recommended, multi-session radiosurgery (mRS) can be the solution. The best treatment schedule for mRS, however, is not well established. The aim of the present retrospective study is to validate the effectiveness of one approach, 25 Gy delivered in 5 fractions in 5 consecutive days, to treat skull base meningiomas. METHODS This is a retrospective multicenter study. Patients with an anterior or a medium skull base meningioma that could not be treated by sRS due to large volume or proximity to the anterior optic pathways (AOPs) underwent 5-fraction mRS. Only patients with at least 36 months follow-up were included in the analysis. Local control and visual outcomes were investigated. RESULTS One-hundred-sixty-seven patients were included in the analysis. One-hundred-one patients underwent RS as a primary indication and 66 were treated after a previous surgery. The median follow-up period was 51 months (range 36-129 months). Progression-free survival at 3, 5 and 8 years were, respectively, 98%, 94% and 90%. Excluding the progressive disease patients, the visual worsening rate was 3.7%. The 42% of the patients with a pre-treatment visual deficit experienced improvement in vision. CONCLUSION 25 Gy delivered in 5 fractions is an effective modality for meningiomas that are near the AOP or are too large to be treated by sRS. The treatment schedule controlled the tumors while sparing visual function.
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Gao F, Li M, Wang Z, Shi L, Lou L, Zhou J. Efficacy and Safety of Gamma Knife Radiosurgery for Meningiomas in Patients with Neurofibromatosis Type 2: A Long-Term Follow-Up Single-Center Study. World Neurosurg 2019; 125:e929-e936. [PMID: 30763746 DOI: 10.1016/j.wneu.2019.01.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To explore the efficacy and safety of Gamma Knife radiosurgery (GKRS) for meningiomas in patients with neurofibromatosis type 2 (NF2). METHODS A series of 35 consecutive patients with 99 meningiomas in our department were retrospectively included from January 2000 to December 2015. Clinical records, magnetic resonance images, and follow-up data were reviewed. RESULTS A total of 35 patients (25 women and 10 men) with 99 NF2-associated meningiomas were identified. All patients initially received GKRS. The patients' median age at the time of GKRS was 40 years (range, 16-61 years). The median prescription dose at the tumor margin was 13 Gy (range, 12-15 Gy). The median follow-up time was 96 months (range, 25-224 months). Twenty-nine patients received GKRS only once, and 6 patients received it multiple times. Six patients (17.1%) had radiation-related complications 7.5 ± 2.4 months after GKRS. Local control rates at 1, 3, and 5 years were 100%, 97.1%, and 90.6%, respectively. Distant control rates at 1, 3, and 5 years were 88.5%, 55.9%, and 45.5%, respectively. Five patients died of concomitant neurologic symptoms. No malignant transformation was observed during the follow-up periods in all 35 patients. CONCLUSIONS GKRS represents an effective and safe management strategy with minimal invasion for patients with NF2-associated meningiomas. Our data showed a high local control rate of NF2-associated meningiomas by GKRS; however, the distant control rate is low, especially in young patients. For these patients, retreatment with GKRS may still be the advisable method.
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Affiliation(s)
- Faliang Gao
- Department of Neurosurgery & Gamma Knife Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Min Li
- Department of Neurosurgery & Gamma Knife Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zheng Wang
- Department of Neurosurgery & Gamma Knife Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Lingfei Shi
- Center for Diagnosis and Treatment of Osteoporosis, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Lin Lou
- Department of Neurosurgery & Gamma Knife Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jia Zhou
- Department of Neurosurgery & Gamma Knife Center, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Wilson HP, Price PM, Ashkan K, Edwards A, Green MM, Cross T, Beaney RP, Davies R, Sibtain A, Plowman NP, Goldsmith C. CyberKnife Radiosurgery of Skull-base Tumors: A UK Center Experience. Cureus 2018; 10:e2380. [PMID: 29805949 PMCID: PMC5969819 DOI: 10.7759/cureus.2380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The study aim was to evaluate patient individualized Cyberknife® treatment for heterogeneous skull-base tumors. Patients treated between 2009 and 2013 at The Harley Street Clinic were studied. In total, 66 patients received 15–30 Gy in 1–5 fractions to a median planning target volume (PTV) of 6.4 cc, including patients with secondary, multiple, residual and recurrent tumors, and those with tumors of uncertain pathological type. Outcome analysis was pragmatically restricted to 35 patients who had single, primary tumors treated with curative intent, and sufficient diagnostic and outcome information. Sixteen vestibular schwannoma patients with median PTV 3.8 cc (range 0.81–19.6) received 18–25 Gy in 3–5 fractions: 81% showed no acute toxicity, 50% reported no late toxicity, 71% of symptoms were stable/improved and local control was 100% at 11.4 months median follow-up. Twelve meningioma patients with median PTV of 5.5 cc (range 0.68–22.3) received 17–30 Gy in 1–5 fractions: 83% experienced no acute toxicity, 33% reported no late toxicity, 88% of symptoms were stable/improved and local control was 100% at 22.1 months median follow-up. Seven patients with other tumor types with median PTV of 24.3 cc (range 7.6–100.5) received 15–28.5 Gy in 1–5 fractions: 57% experienced no acute toxicity, 57% reported no late toxicities, 66% of symptoms were stable and local control was 43% at 14.9 months median follow-up. When tumor types were considered together, smaller tumors (PTV < 6.4 cc) showed reduced acute toxicity (p = 0.01). Overall, smaller benign tumors showed low acute toxicity, excellent local control, and good symptom management: a focus on enhanced neurological preservation may refine outcomes. For other tumor types outcome was encouraging: a focus on optimal dose and fractionation scheduling may reduce toxicity and improve local control. Individual patient experiences are detailed where valuable lessons were gained for optimizing local control and minimizing toxicity.
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Affiliation(s)
- Hannah P Wilson
- Department of Surgery and Cancer, Imperial College London, London, GBR
| | - Patricia M Price
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Keyoumars Ashkan
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Andrew Edwards
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Melanie M Green
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Timothy Cross
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Ronald P Beaney
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Rhiannon Davies
- Department of Neuro Oncology, Guy's and St. Thomas' Hospital, London, GBR
| | - Amen Sibtain
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
| | - Nick P Plowman
- Department of Radiation Oncology, The Harley Street Clinic, London, GBR
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Patibandla MR, Lee CC, Sheehan J. Stereotactic Radiosurgery of Central Skull Base Meningiomas—Volumetric Evaluation and Long-Term Outcomes. World Neurosurg 2017; 108:176-184. [DOI: 10.1016/j.wneu.2017.08.166] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/25/2017] [Accepted: 08/26/2017] [Indexed: 10/18/2022]
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16
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Azar M, Kazemi F, Jahanbakhshi A, Chanideh I, Jalessi M, Amini E, Geraily G, Farhadi M. Gamma Knife Radiosurgery for Cavernous Sinus Meningiomas: Analysis of Outcome in 166 Patients. Stereotact Funct Neurosurg 2017; 95:259-267. [DOI: 10.1159/000478024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 06/05/2017] [Indexed: 11/19/2022]
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Pinzi V, Biagioli E, Roberto A, Galli F, Rizzi M, Chiappa F, Brenna G, Fariselli L, Floriani I. Radiosurgery for intracranial meningiomas: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2017; 113:122-134. [DOI: 10.1016/j.critrevonc.2017.03.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 01/30/2017] [Accepted: 03/08/2017] [Indexed: 10/20/2022] Open
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Kim M, Lee DH, Kim Rn HJ, Cho YH, Kim JH, Kwon DH. Analysis of the results of recurrent intracranial meningiomas treated with re-radiosurgery. Clin Neurol Neurosurg 2016; 153:93-101. [PMID: 28081463 DOI: 10.1016/j.clineuro.2016.12.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/23/2016] [Accepted: 12/26/2016] [Indexed: 12/15/2022]
Abstract
OBJECTS Meningioma is the most common intracranial neoplasm, comprising approximately 30% of all primary intracranial tumors (Claus et al., 2005) [1]. Treatment options include observation, microsurgical resection, stereotactic radiosurgery (SRS), and whole brain radiation therapy (WBRT). Gamma knife radiosurgery (GKRS) is a very effective treatment for intracranial meningiomas; previous studies showed the tumor control rate at 5-10 years of follow-up as 84.3%-100% in all cases (Feigl et al., 2005; Linskey et al., 2005; Malik et al., 2005; Aichholzer et al., 2000; Hakim et al., 1998; Chang and Adler 1997; Lunsford, 1994; Ganz et al., 1993) [2-9]. Many studies have discussed issues like optimal dose, conformal configurations, and adverse effects to improve the treatment result with GKRS (Malik et al., 2005; Kenai et al., 2005; Rowe et al., 2004; Shrieve et al., 2004) [4,10-12]. There are some cases in which the radiosurgery result is unfavorable and perhaps further treatment is needed. In these cases, re-radiosurgery can be an option. However, there have not been comprehensive studies discussing the issues of re-radiosurgery. Therefore, we analyzed the result of re-radiosurgery for recurrent meningiomas and their impact on clinical outcomes. METHODS From 1995 to 2015, we retrospectively reviewed 1163 patients who underwent GKRS for intracranial meningioma at the Asan Medical Center. Patients with multiple meningiomas or a follow-up with a period of less than a year were excluded from this study. Finally, 865 patients were enrolled in this study. Clinical symptoms and brain magnetic resonance imaging (MRI) scans were assessed by neurosurgeons. When tumor size increased together with newly developed neurologic symptoms, further management, such as microsurgical resection or SRS, was considered. Histologic analysis of the resected tumors was performed by neuropathologists. Clinical data, including patient's sex, age, and tumor locations were recorded. Treatment data included tumor volume, tumor grade, radiation dose, and presence of edema. Final outcome data including follow-up period, time to progression, interval between first and second radiosurgery courses and interval between microsurgery and radiosurgery were obtained. RESULTS Among 865 patients, tumor recurrence was found in 63 patients (7.28%). Seven patients showed transient tumor growth after GKRS. These patients have been under close observation without any further treatments. Fifty-six patients (6.47%) showed permanent tumor growth on follow-up MRI. Thirty-three patients from this group underwent repeated radiosurgery owing to tumor growth, resulting in a re-irradiation rate of 3.82% at our radiosurgery center. The other 23 patients were treated using methods other than re-radiosurgery. Among the 33 patients, 25 underwent microsurgical resection prior to their initial course of GKRS, and the other 8 were treated with re-radiosurgery only. An analysis was performed to determine factors that may have a role in treatment results. Of the many variables, tumor grade (p=0.004, Fisher's exact test) was the only significant factor for progression-free survival (PFS). Thirteen patients with unbiopsied or benign meningioma showed stable tumor size, while there was tumor growth in 8 patients. Among high-grade meningioma patients, 3 and 9 showed stable disease and tumor growth, respectively. As a result of re-radiosurgery, 11 out of 17 patients showed tumor growth and needed further treatments; this involved a third GKRS for 4 patients, microsurgical resection for 6 patients, and cyber knife radiosurgery (CKRS) for 1 patient. Four patients from this group were also treated with WBRT. CONCLUSION We analyzed the results of re-radiosurgery for recurrent meningiomas and observed that World Health Organization (WHO) grade II and III was significantly associated with a lower PFS rate compared with low-grade meningiomas (p=0.004). Conversely, patients with benign meningioma or unbiopsied tumors had much better results. Hence, re-radiosurgery is recommended for patients with unknown or benign meningiomas if their first GKRS result is unsatisfactory. However, re-radiosurgery should be considered carefully for recurrent high-grade tumors. Owing to the small number of recurrent meningioma patients treated with re-radiosurgery, further studies are required to delineate the role of this treatment.
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Affiliation(s)
- Moinay Kim
- Graduate School of Medicine, University of Ulsan, Seoul 05505, Republic of Korea
| | - Do Hee Lee
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Republic of Korea
| | - Hyun Jung Kim Rn
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Republic of Korea
| | - Young Hyun Cho
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Republic of Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Republic of Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Republic of Korea.
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Fossati P, Vavassori A, Deantonio L, Ferrara E, Krengli M, Orecchia R. Review of photon and proton radiotherapy for skull base tumours. Rep Pract Oncol Radiother 2016; 21:336-55. [PMID: 27330419 DOI: 10.1016/j.rpor.2016.03.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/01/2016] [Accepted: 03/30/2016] [Indexed: 11/18/2022] Open
Abstract
An extremely large variety of benign and malignant tumours occur at skull base; these tumour lesions are in the proximity to structures deputed to relevant physiologic functions, limiting extensive surgical approaches to this body district. Most recent progresses of surgery and radiotherapy have allowed to improve local control with acceptable rates of side effects. Various photon radiotherapy techniques are employed, including 3-dimensional conformal radiotherapy, intensity modulated radiotherapy (IMRT), stereotactic radiotherapy (SRT) and brachytherapy that is manly limited to the treatment of primary or recurrent nasopharyngeal carcinoma. Proton beam radiotherapy is also extensively used thanks to its physical characteristics. Our review, focusing in particular on meningioma, chordoma, and chondrosarcoma, suggests that proton therapy plays a major role in the treatment of malignant tumours whereas photon therapy still plays a relevant role in the treatment of benign tumour lesions.
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Affiliation(s)
- Piero Fossati
- Radiotherapy Division, IEO, Milan, Italy; Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | | | - Letizia Deantonio
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy; Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy
| | - Eleonora Ferrara
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy
| | - Marco Krengli
- Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy; Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy; Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy
| | - Roberto Orecchia
- Radiotherapy Division, IEO, Milan, Italy; Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
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Bunc G, Ravnik J, Ravnik M, Velnar T. Partial skull base tumour resection in combination with radiosurgery: an escape procedure or a reasonable solution of treatment? Wien Klin Wochenschr 2015; 127 Suppl 5:S270-6. [PMID: 25925166 DOI: 10.1007/s00508-015-0787-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 04/04/2015] [Indexed: 10/23/2022]
Abstract
Despite advancement in microsurgical techniques for skull base tumour surgery, approaches of this kind still represent a significant challenge for neurosurgeons due to the size of the tumour and its interference and proximity to important neural and vascular structures. After incomplete resection, gamma knife radiosurgery is becoming an alternative or adjunctive treatment option. In this article, some examples of our experience in combined treatment of the skull base tumours with surgical procedure and gamma knife therapy for the remaining tumour tissue are presented.
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Affiliation(s)
- Gorazd Bunc
- Department of Neurosurgery, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Janez Ravnik
- Department of Neurosurgery, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Maja Ravnik
- Department of Oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia. .,Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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21
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Clinical characteristics of patients with asymptomatic intracranial meningiomas and results of their surgical management. Neurosurg Rev 2015; 38:481-8; discussion 488. [DOI: 10.1007/s10143-015-0619-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/15/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
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22
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Starke RM, Przybylowski CJ, Sugoto M, Fezeu F, Awad AJ, Ding D, Nguyen JH, Sheehan JP. Gamma Knife radiosurgery of large skull base meningiomas. J Neurosurg 2015; 122:363-72. [DOI: 10.3171/2014.10.jns14198] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Stereotactic radiosurgery (SRS) has become a common treatment modality for intracranial meningiomas. Skull base meningiomas greater than 8 cm3 in volume have been found to have worse outcomes following SRS. When symptomatic, patients with these tumors are often initially treated with resection. For tumors located in close proximity to eloquent structures or in patients unwilling or unable to undergo a resection, SRS may be an acceptable therapeutic approach. In this study, the authors review the SRS outcomes of skull base meningiomas greater than 8 cm3 in volume, which corresponds to a lesion with an approximate diameter of 2.5 cm.
METHODS
The authors reviewed the data in a prospectively compiled database documenting the outcomes of 469 patients with skull base meningiomas treated with single-session Gamma Knife radiosurgery (GKRS). Seventy-five patients had tumors greater than 8 cm3 in volume, which was defined as a large tumor. All patients had a minimum follow-up of 6 months, but patients were included if they had a complication at any time point. Thirty patients were treated with upfront GKRS, and 45 were treated following microsurgery. Patient and tumor characteristics were assessed to determine predictors of new or worsening neurological function and tumor progression following GKRS.
RESULTS
After a mean follow-up of 6.5 years (range 0.5–21 years), the tumor volume was unchanged in 37 patients (49%), decreased in 26 patients (35%), and increased in 12 patients (16%). Actuarial rates of progression-free survival at 3, 5, and 10 years were 90.3%, 88.6%, and 77.2%, respectively. Four patients had new or worsened edema following GKRS, but preexisting edema decreased in 3 patients. In Cox multivariable analysis, covariates associated with tumor progression were 1) presentation with any cranial nerve (CN) deficit from III to VI (hazard ratio [HR] 3.78, 95% CI 1.91–7.45; p < 0.001), history of radiotherapy (HR 12.06, 95% CI 2.04–71.27; p = 0.006), and tumor volume greater than 14 cm3 (HR 6.86, 95% CI 0.88–53.36; p = 0.066). In those patients with detailed clinical follow-up (n = 64), neurological function was unchanged in 37 patients (58%), improved in 16 patients (25%), and deteriorated in 11 patients (17%). In multivariate analysis, the factors predictive of new or worsening neurological function were history of surgery (OR 3.00, 95% CI 1.13–7.95; p = 0.027), presentation with any CN deficit from III to VI (OR 3.94, 95% CI 1.49–10.24; p = 0.007), and decreasing maximal dose (OR 0.76, 95% CI 0.63–0.93; p = 0.007). Tumor progression was present in 64% of patients with new or worsening neurological decline.
CONCLUSIONS
Stereotactic radiosurgery affords a reasonable rate of tumor control for large skull base meningiomas and does so with a low incidence of neurological deficits. Those with a tumor less than 14 cm3 in volume and without presenting CN deficit from III to VI were more likely to have effective tumor control.
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Affiliation(s)
| | | | - Mukherjee Sugoto
- 3Neuroradiology, University of Virginia Health System, Charlottesville, Virginia
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Nowak A, Dziedzic T, Czernicki T, Kunert P, Marchel A. Surgical treatment of jugular foramen meningiomas. Neurol Neurochir Pol 2014; 48:391-6. [PMID: 25482249 DOI: 10.1016/j.pjnns.2014.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 09/04/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECT We present our experience with surgery of jugular foramen meningiomas with special consideration of clinical presentation, surgical technique, complications, and outcomes. METHODS This retrospective study includes three patients with jugular foramen meningiomas treated by the senior author between January 2005 and December 2010. The initial symptom for which they sought medical help was decreased hearing. In all of the patients there had been no other neurological symptoms before surgery. The transcondylar approach with sigmoid sinus ligation at jugular bulb was suitable in each case. RESULTS No death occurred in this series. All of the patients deteriorated after surgery mainly due to the new lower cranial nerves palsy occurred. The lower cranial nerve dysfunction had improved considerably at the last follow-up examination but no patient fully recovered. Two of three patients with preoperatively impaired yet functional hearing deteriorated after surgery with no subsequent cranial nerve VIII function improvement. In one case postoperative stereotactic radiosurgery was performed due to non-radical tumour resection (Simpson Grade IV) and tumour remnant proved stable in the 4-year follow-up. None of the patients have shown signs of tumour recurrence in the mean follow-up period of 56 months. CONCLUSIONS Jugular foramen meningiomas represent one of the rarest subgroups of meningiomas and their surgical treatment is associated with significant risk of permanent cranial nerve deficits.
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Affiliation(s)
- Arkadiusz Nowak
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Warszawa, Poland.
| | - Tomasz Dziedzic
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Warszawa, Poland
| | - Tomasz Czernicki
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Warszawa, Poland
| | - Przemysław Kunert
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Warszawa, Poland
| | - Andrzej Marchel
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Warszawa, Poland
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Aboukais R, Zairi F, Reyns N, Le Rhun E, Touzet G, Blond S, Lejeune JP. Surgery followed by radiosurgery: A deliberate valuable strategy in the treatment of intracranial meningioma. Clin Neurol Neurosurg 2014; 124:123-6. [DOI: 10.1016/j.clineuro.2014.06.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 06/23/2014] [Accepted: 06/29/2014] [Indexed: 10/25/2022]
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25
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Vera E, Iorgulescu JB, Raper DMS, Madhavan K, Lally BE, Morcos J, Elhammady S, Sherman J, Komotar RJ. A review of stereotactic radiosurgery practice in the management of skull base meningiomas. J Neurol Surg B Skull Base 2014; 75:152-8. [PMID: 25072008 DOI: 10.1055/s-0033-1354747] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/01/2013] [Indexed: 01/09/2023] Open
Abstract
Gross total resection of skull base meningiomas poses a surgical challenge due to their proximity to neurovascular structures. Once the gold standard therapy for skull base meningiomas, microsurgery has been gradually replaced by or used in combination with stereotactic radiosurgery (SRS). This review surveys the safety and efficacy of SRS in the treatment of cranial base meningiomas including 36 articles from 1991 to 2010. SRS produces excellent tumor control with low morbidity rates compared with surgery alone for asymptomatic small skull base meningiomas, patients with risk factors precluding conventional surgery, and as adjuvant therapy for recurrent or residual lesions.
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Affiliation(s)
- Elena Vera
- Department of Anesthesiology, University of Texas Medical Center, Houston, Texas, United States
| | - J Bryan Iorgulescu
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, United States
| | - Daniel M S Raper
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
| | - Karthik Madhavan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Brian E Lally
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Jacques Morcos
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Samy Elhammady
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Jonathan Sherman
- Department of Neurosurgery, George Washington University School of Medicine, Washington, District of Columbia, United States
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
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Delannes M, Maire JP, Sabatier J, Thillays F. Radiothérapie stéréotaxique des méningiomes intracrâniens. Cancer Radiother 2012; 16 Suppl:S79-89. [DOI: 10.1016/j.canrad.2011.07.249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 07/29/2011] [Indexed: 10/28/2022]
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Pham MH, Zada G, Mosich GM, Chen TC, Giannotta SL, Wang K, Mack WJ. Molecular genetics of meningiomas: a systematic review of the current literature and potential basis for future treatment paradigms. Neurosurg Focus 2011; 30:E7. [PMID: 21529178 DOI: 10.3171/2011.2.focus1117] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although a majority of meningiomas are benign neoplasms, those occurring at the cranial base may be challenging tumors to treat because of extensive tissue invasion, an inability to achieve gross-total microscopic resection, and local tumor recurrence and/or progression. A more comprehensive understanding of the genetic abnormalities associated with meningioma tumorigenesis, growth, and invasion may provide novel targets for grading assessments and individualizing molecular therapies for skull base meningiomas. The authors performed a review of the current literature to identify genes that have been associated with the formation and/or progression of meningiomas. Mutations in the NF2 gene have been most commonly implicated in the formation of the majority of meningiomas. Inactivation of other tumor suppressor genes, including DAL-1 and various tissue inhibitors of matrix metalloproteinases, upregulation of several oncogenes including c-sis and STAT3, and signaling dysregulation of pathways such as the Wnt pathway, have each been found to play important, and perhaps, complementary roles in meningioma development, progression, and recurrence. Identification of these genetic factors using genome-wide association studies and high-throughput genomics may provide data for future individualized treatment strategies.
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Affiliation(s)
- Martin H Pham
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA.
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Schulz C, Mathieu R, Kunz U, Mauer UM. Treatment of unresectable skull base meningiomas with somatostatin analogs. Neurosurg Focus 2011; 30:E11. [PMID: 21529167 DOI: 10.3171/2011.1.focus111] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The standard surgical treatment for meningiomas is total resection, but the complete removal of skull base meningiomas can be difficult for several reasons. Thus, the management of certain meningiomas of the skull base--for example, those involving basal vessels and cranial nerves--remains a challenge. In recent reports it has been suggested that somatostatin (SST) administration can cause growth inhibition of unresectable and recurrent meningiomas. The application of SST and its analogs is not routinely integrated into standard treatment strategies for meningiomas, and clinical studies proving growth-inhibiting effects do not exist. The authors report on their experience using octreotide in patients with recurrent or unresectable meningiomas of the skull base. METHODS Between January 1996 and December 2010, 13 patients harboring a progressive residual meningioma (as indicated by MR imaging criteria) following operative therapy were treated with a monthly injection of the SST analog octreotide (Sandostatin LAR [long-acting repeatable] 30 mg, Novartis). Eight of 13 patients had a meningioma of the skull base and were analyzed in the present study. Postoperative tumor enlargement was documented in all patients on MR images obtained before the initiation of SST therapy. All tumors were benign. No patient received radiation or chemotherapy before treatment with SST. The growth of residual tumor was monitored by MR imaging every 12 months. RESULTS Three of the 8 patients had undergone surgical treatment once; 3, 2 times; and 2, 3 times. The mean time after the last meningioma operation (before starting SST treatment) and tumor enlargement as indicated by MR imaging criteria was 24 months. A total of 643 monthly cycles of Sandostatin LAR were administered. Five of the 8 patients were on SST continuously and stabilized disease was documented on MR images obtained in these patients during treatment (median 115 months, range 48-180 months). Three of the 8 patients interrupted treatment: after 60 months in 1 case because of tumor progression, after 36 months in 1 case because of side effects, and after 36 months in 1 case because the health insurance company denied cost absorption. CONCLUSIONS Although no case of tumor regression was detected on MR imaging, the study results indicated that SST analogs can arrest the progression of unresectable or recurrent benign meningiomas of the skull base in some patients. It remains to be determined whether a controlled prospective clinical trial would be useful.
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Affiliation(s)
- Chris Schulz
- Neurosurgical Clinic, German Armed Forces Military Hospital Ulm, Oberer Eselsberg 40, Ulm, Germany.
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Chen CM, Huang APH, Kuo LT, Tu YK. Contemporary surgical outcome for skull base meningiomas. Neurosurg Rev 2011; 34:281-96; discussion 296. [PMID: 21614426 DOI: 10.1007/s10143-011-0321-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 02/03/2011] [Accepted: 03/06/2011] [Indexed: 11/25/2022]
Abstract
Although surgical excision of meningioma and its dural base is the most common primary management, skull base meningiomas are quite different, and contemporary management usually consists of multimodal treatment with the aim of achieving the best possible functional outcome and quality of life (QOL) for these patients. As surgery plays an important role in the treatment of skull base meningiomas, it is crucial for neurosurgeons to appreciate the surgical outcome and QOL after meningioma surgery. Outcome is usually measured for meningiomas in terms of morbidity, mortality, time to recurrence, and QOL. The extent of resection, tumor grade, proliferative markers, and tumor location are significant factors in predicting the surgical outcome. Therefore, we address each of these factors in detail in this review. Advances in recent decades in microsurgical techniques, neuroimaging modalities, neuroanesthesia, and perioperative intensive care have substantially improved the surgical outcome; therefore, most surgical outcomes discussed in this review are cited from contemporary literature (2000 to the present) in order to depict the surgical outcome of contemporary microsurgery.
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Affiliation(s)
- Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.
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Starke RM, Nguyen JH, Rainey J, Williams BJ, Sherman JH, Savage J, Yen CP, Sheehan JP. Gamma Knife surgery of meningiomas located in the posterior fossa: factors predictive of outcome and remission. J Neurosurg 2011; 114:1399-409. [DOI: 10.3171/2010.11.jns101193] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although numerous studies have analyzed the role of stereotactic radiosurgery for intracranial meningiomas, few studies have assessed outcomes of posterior fossa meningiomas after stereotactic radiosurgery. In this study, the authors evaluate the outcomes of posterior fossa meningiomas treated with Gamma Knife surgery (GKS). The authors also assess factors predictive of new postoperative neurological deficits and tumor progression.
Methods
A retrospective review was performed of a prospectively compiled database documenting the outcomes of 152 patients with posterior fossa meningiomas treated at the University of Virginia from 1990 to 2006. All patients had a minimum follow-up of 24 months. There were 30 males and 122 females, with a median age of 58 years (range 12–82 years). Seventy-five patients were treated with radiosurgery initially, and 77 patients were treated with GKS after resection. Patients were assessed clinically and radiographically at routine intervals following GKS. Factors predictive of new neurological deficit following GKS were assessed via univariate and multivariate analysis, and Kaplan-Meier analysis and Cox multivariate regression analysis were used to assess factors predictive of tumor progression.
Results
Patients had meningiomas centered over the tentorium (35 patients, 23%), cerebellopontine angle (43 patients, 28%), petroclival region (28 patients, 18%), petrous region (6 patients, 4%), and clivus (40 patients, 26%). The median follow-up was 7 years (range 2–16 years). The mean preradiosurgical tumor volume was 5.7 cm3 (range 0.3–33 cm3), and mean postradiosurgical tumor volume was 4.9 cm3 (range 0.1–33 cm3). At last follow-up, 55 patients (36%) displayed no change in tumor volume, 78 (51%) displayed a decrease in volume, and 19 (13%) displayed an increase in volume. Kaplan-Meier analysis demonstrated radiographic progression-free survival at 3, 5, and 10 years to be 98%, 96%, and 78%, respectively. In Cox multivariable analysis, pre-GKS covariates associated with tumor progression included age greater than 65 years (hazard ratio [HR] 3.24, 95% CI 1.12–9.37; p = 0.03) and a low dose to the tumor margin (HR 0.76, 95% CI 0.60–0.97; p = 0.03), and post-GKS covariates included shunt-dependent hydrocephalus (HR 25.0, 95% CI 3.72–100.0; p = 0.001). At last clinical follow-up, 139 patients (91%) demonstrated no change or improvement in their neurological condition, and 13 patients showed symptom deterioration (9%). In multivariate analysis, the only factors predictive of new or worsening symptoms were clival or petrous location (OR 4.0, 95% CI 1.1–13.7; p = 0.03).
Conclusions
Gamma Knife surgery offers an acceptable rate of tumor control for posterior fossa meningiomas and accomplishes this with a low incidence of neurological deficits. In patients selected for GKS, tumor progression is associated with age greater than 65 years and decreasing dose to the tumor margin. Clival- or petrous-based locations are predictive of an increased risk of new or worsening neurological deficit following GKS.
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31
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Ohba S, Kobayashi M, Horiguchi T, Onozuka S, Yoshida K, Ohira T, Kawase T. Long-term surgical outcome and biological prognostic factors in patients with skull base meningiomas. J Neurosurg 2010; 114:1278-87. [PMID: 21166572 DOI: 10.3171/2010.11.jns10701] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although gross-total resection (GTR) is a preferable treatment for skull base meningiomas, subtotal resection (STR) with or without radiation therapy can be considered as an alternative treatment for patients at considerable surgical risk. The long-term prognosis of such patients might be related to the biological activity of the tumor. This study examined predictors of progression-free survival (PFS) and sought to determine the optimal treatment strategies, focusing on the pathobiological findings of skull base meningiomas. METHODS This study included 281 patients with skull base meningiomas (mean follow-up period 88.4 months). Risk factors for tumor progression were examined using a multivariate analysis. The PFS and overall survival (OS) rates were evaluated using the Kaplan-Meier method. The functional outcomes of the patients were measured using the Karnofsky Performance Scale (KPS). RESULTS The 10-year PFS and OS rates were 66.4% and 97.4%, respectively. Overall, 83.3% of patients achieved a favorable outcome, that is, an improved or unchanged KPS score. The extent of resection, additional radiotherapy, histological grade, MIB-1 index, and p53-positive rate were significantly associated with PFS. The PFS of patients undergoing STR without radiation therapy was significantly shorter than that of either those undergoing STR with radiation therapy or GTR, while no statistical difference was observed between the latter 2 groups. Among the patients undergoing STR with pathobiological risk factors (histological grade, MIB-1 index, and p53-positive rate), the PFS of the patients who received radiation therapy was better than that of those who did not receive radiation therapy. Among the patients undergoing STR without such risk factors, the PFS was not significantly different between patients who received radiation therapy and those who did not. CONCLUSIONS For patients with skull base meningiomas, a GTR is desirable and additional radiation therapy after STR may contribute to a longer PFS. Additional radiation therapy should be recommended, especially for patients with pathobiological risk factors, but not necessarily for those without such risks.
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Affiliation(s)
- Shigeo Ohba
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.
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Stereotactic radiosurgery: a meta-analysis of current therapeutic applications in neuro-oncologic disease. J Neurooncol 2010; 103:1-17. [DOI: 10.1007/s11060-010-0360-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 08/09/2010] [Indexed: 10/18/2022]
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Igaki H, Maruyama K, Koga T, Murakami N, Tago M, Terahara A, Shin M, Nakagawa K, Ohtomo K. Stereotactic radiosurgery for skull base meningioma. Neurol Med Chir (Tokyo) 2010; 49:456-61. [PMID: 19855141 DOI: 10.2176/nmc.49.456] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Stereotactic radiosurgery is now a treatment option for meningiomas, especially for high-risk patients such as those with skull base lesions. The clinical outcomes were retrospectively analyzed of stereotactic radiosurgery using the Leksell Gamma Knife((R)) performed for 98 patients with 106 skull base meningiomas at the University of Tokyo Hospital between June 1990 and April 2006 and followed up for more than a year. After a median follow-up period of 53.2 months (range 12.2-204.4 months), local tumor control rates were 86.9% and 78.9% at 5 years and 10 years, respectively. Tumors with volume of 4 cm(3) or smaller (97.5% vs. 76.1% at 5 years, p = 0.001) and tumors completely included within the isodose line of 14 Gy or more (97.5% vs. 67.2% at 5 years, p = 0.0006) had higher local control rates. Postoperative residual tumors treated by stereotactic radiosurgery were controlled in all 25 cases. Cranial nerve deficits were improved, stable, and deteriorated in 12, 64, and 3 patients, respectively, after stereotactic radiosurgery. Stereotactic radiosurgery was effective treatment method for local control of skull base meningiomas, especially for small or postoperative residual tumors. Correct combination of microsurgery and radiosurgery leads to excellent local control.
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Affiliation(s)
- Hiroshi Igaki
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan.
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Minniti G, Amichetti M, Enrici RM. Radiotherapy and radiosurgery for benign skull base meningiomas. Radiat Oncol 2009; 4:42. [PMID: 19828022 PMCID: PMC2768735 DOI: 10.1186/1748-717x-4-42] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 10/14/2009] [Indexed: 11/28/2022] Open
Abstract
Meningiomas located in the region of the base of skull are difficult to access. Complex combined surgical approaches are more likely to achieve complete tumor removal, but frequently at a cost of treatment related high morbidity. Local control following subtotal excision of benign meningiomas can be improved with conventional fractionated external beam radiation therapy with a reported 5-year progression-free survival up to 95%. New radiation techniques, including stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), and intensity-modulated radiotherapy (IMRT) have been developed as a more accurate technique of irradiation with more precise tumor localization, and consequently a reduction in the volume of normal brain irradiated to high radiation doses. SRS achieves a high tumour control rate in the range of 85-97% at 5 years, although it should be recommended only for tumors less than 3 cm away more than 3 mm from the optic pathway because of high risk of long-term neurological deficits. Fractionated RT delivered as FSRT, IMRT and protons is useful for larger and irregularly or complex-shaped skull base meningiomas close to critical structures not suitable for single-fraction SRS. The reported results indicate a high tumour control rate in the range of 85-100% at 5 years with a low risk of significant incidence of long-term toxicity. Because of the long natural history of benign meningiomas, larger series and longer follow-up are necessary to compare results and toxicity of different techniques.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiotherapy Oncology, Sant' Andrea Hospital, University La Sapienza, Rome, Italy.
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Kim IY, Kondziolka D, Niranjan A, Flickinger JC, Lunsford LD. Gamma knife radiosurgery for intraventricular meningiomas. Acta Neurochir (Wien) 2009; 151:447-52; discussion 452. [PMID: 19337685 DOI: 10.1007/s00701-009-0273-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 02/25/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE Intraventricular meningiomas are relatively rare tumors that may benefit from stereotactic radiosurgery as a minimally invasive treatment strategy. We report our experience using gamma knife radiosurgery (GKR) for intraventricular meningiomas. METHODS Over a 16-year period, we identified 9 patients with intraventricular meningiomas who were eligible for GKR out of a total management experience of 1,045 patients. The mean patient age was 51 years (range, 14 to 81). Three had radiosurgery for recurrent tumors after prior resection, and GKR was used as an adjunctive after subtotal resection in 1 patient. In the other 5 patients, GKR was used as primary management. Two had a diagnosis of meningioma confirmed by biopsy. The median tumor volume at GKR was 3.9 cc (range, 0.8-11.8). A median margin dose of 16.0 Gy (range, 14.0-22.5) was delivered to the tumor margin. RESULTS The average follow-up was 64 months. None of the patients developed hydrocephalus or treatment-related morbidity. The progression-free periods after radiosurgery varied from 7 to 160 months (mean, 60). Four tumors regressed and 2 remained unchanged. Three patients showed delayed tumor progression. Meningioma growth control was obtained in 7 out of 9 patients, but 1 patient required two radiosurgical procedures. CONCLUSIONS Gamma knife radiosurgery may be an additional minimally invasive management option for small intraventricular meningiomas in patients who either fail or are unsuitable for resection.
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Affiliation(s)
- In-Young Kim
- Department of Neurological Surgery, Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
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Coppa ND, Raper DMS, Zhang Y, Collins BT, Harter KW, Gagnon GJ, Collins SP, Jean WC. Treatment of malignant tumors of the skull base with multi-session radiosurgery. J Hematol Oncol 2009; 2:16. [PMID: 19341478 PMCID: PMC2678153 DOI: 10.1186/1756-8722-2-16] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Accepted: 04/02/2009] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Malignant tumors that involve the skull base pose significant challenges to the clinician because of the proximity of critical neurovascular structures and limited effectiveness of surgical resection without major morbidity. The purpose of this study was to evaluate the efficacy and safety of multi-session radiosurgery in patients with malignancies of the skull base. METHODS Clinical and radiographic data for 37 patients treated with image-guided, multi-session radiosurgery between January 2002 and December 2007 were reviewed retrospectively. Lesions were classified according to involvement with the bones of the base of the skull and proximity to the cranial nerves. RESULTS Our cohort consisted of 37 patients. Six patients with follow-up periods less than four weeks were eliminated from statistical consideration, thus leaving the data from 31 patients to be analyzed. The median follow-up was 37 weeks. Ten patients (32%) were alive at the end of the follow-up period. At last follow-up, or the time of death from systemic disease, tumor regression or stable local disease was observed in 23 lesions, representing an overall tumor control rate of 74%. For the remainder of lesions, the median time to progression was 24 weeks. The median progression-free survival was 230 weeks. The median overall survival was 39 weeks. In the absence of tumor progression, there were no cranial nerve, brainstem or vascular complications referable specifically to CyberKnife radiosurgery. CONCLUSION Our experience suggests that multi-session radiosurgery for the treatment of malignant skull base tumors is comparable to other radiosurgical techniques in progression-free survival, local tumor control, and adverse effects.
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Affiliation(s)
- Nicholas D Coppa
- Department of Neurosurgery, Georgetown University Hospital, Washington, DC, USA.
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Gamma Knife Radiosurgery for Skull Base Meningiomas: Long-Term Radiologic and Clinical Outcome. Int J Radiat Oncol Biol Phys 2008; 72:1324-32. [DOI: 10.1016/j.ijrobp.2008.03.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Revised: 02/02/2008] [Accepted: 03/06/2008] [Indexed: 11/19/2022]
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Mandelli C, Porras L, López-Sánchez C, Sicuri GM, Lomonaco I, García-Martínez V. The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas. A quantitative anatomic comparison with other approaches to the same region. Neurocirugia (Astur) 2008; 19:133-42. [PMID: 18500412 DOI: 10.1016/s1130-1473(08)70237-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The partial labyrinthectomy petrous apicectomy (PLPA) approach is a transpetrous route that provides the advantages of the labyrinthine removal but with hearing preservation. Using seven temporal bone tissue blocks and three formaldehyde-fixed cadaveric heads we have made a morphometric and comparative study on this approach that summarizes the invasiveness, the optimal surgical exposure, the anatomic complexity of the skull base approaches and, on the other hand, the spirit of preservation that is the constant aim of modern neurosurgery. The morphometric analysis is designed to make the bony phase of the PLPA approach safer and to define the relationship between petrous landmarks. The comparative study is made between the PLPA and other neurosurgical routes enhancing the potentiality of the PLPA approach that permits a wider angle of incidence towards the brainstem than with the retrosigmoid routes.
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Affiliation(s)
- C Mandelli
- Department of Neurosurgery, IRCCS San Raffaele, Università Vita-Salute. Milano, Italy
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Choi YJ, Lee JI, Kim YD. Gamma Knife Radiosurgery for Orbital Lesions. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.4.555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Young-Joo Choi
- Department of Ophthalmology, Ulsan University Hospital, Ulsan University School of Medicine, Ulsan, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Duck Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Davidson L, Fishback D, Russin JJ, Weiss MH, Yu C, Pagnini PG, Zelman V, Apuzzo MLJ, Giannotta SL. Postoperative Gamma Knife surgery for benign meningiomas of the cranial base. Neurosurg Focus 2007; 23:E6. [PMID: 17961043 DOI: 10.3171/foc-07/10/e6] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The standard treatment for meningiomas is complete resection, but the proximity of skull base meningiomas to important neurovascular structures makes complete excision of the lesion difficult or impossible. The authors analyzed the mid- and long-term results obtained in patients treated with postresection Gamma Knife surgery (GKS) for residual or recurrent benign meningiomas of the cranial base. METHODS Thirty-six patients with residual or recurrent benign meningiomas of the skull base following one or more surgical procedures underwent GKS. There were 31 women and five men, ranging in age from 22 to 73 years. The median tumor volume was 4.1 ml (range 0.8-20 ml) and the median radiation dose to the tumor margin was 16 Gy (range 15-16 Gy). RESULTS Patients were followed for a median of 81 months (range 30-141 months) after GKS. At the end of the follow-up period, overall neurological improvement was observed in 16 patients (44.4%), whereas the condition in 20 patients (55.6%) was unchanged. One patient suffered transient cerebral edema 6 months after GKS. Based on imaging documentation, a partial response was seen in five patients (13.9%), the disease remained stable in 30 patients (83.3%), and in one patient (2.8%) there was an increase in tumor size. The actuarial progression-free survival rate was 100% at 5 years and 94.7% at 10 years. CONCLUSIONS Gamma Knife surgery was shown to be an excellent adjunct to resection because of its durable rate of tumor control and low toxicity. It should be initially considered along with surgery for the treatment of complex skull base meningiomas.
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Affiliation(s)
- Laurence Davidson
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Kollová A, Liscák R, Novotný J, Vladyka V, Simonová G, Janousková L. Gamma Knife surgery for benign meningioma. J Neurosurg 2007; 107:325-36. [PMID: 17695387 DOI: 10.3171/jns-07/08/0325] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Meningioma is the most frequent benign tumor treated with Gamma Knife surgery (GKS); however, the assessment of its efficacy and safety in slow-growing tumors is an ongoing process, requiring analysis of long-term results.
Methods
Three hundred sixty-eight patients harboring 400 meningiomas treated between 1992 and 1999 at Na Homolce Hospital were evaluated. The median patient age was 57 years (range 18–84 years). The median tumor volume was 4.4 cm3 (range 0.11–44.9 cm3). The median tumor margin dose to the 50% isodose line was 12.55 Gy (range 6.5–24 Gy). Descriptive analysis was performed in 331 patients (90%); 325 patients had a follow-up longer than 24 months (median 60 months), and six patients were included because of posttreatment complications. The volume of treated tumors decreased in 248 cases (69.7%), remained the same in 99 (27.8%), and increased in nine (2.5%). The actuarial tumor control rate was 97.9% at 5 years post-GKS. Perilesional edema after radiosurgery was confirmed on neuroim-aging in 51 patients (15.4%). The temporary and permanent morbidity rates after radiosurgery were 10.2 and 5.7%, respectively.
Results
A significantly higher incidence of tumor volume increase was observed in men compared with women and in tumors treated with a margin dose lower than 12 Gy. Significant risk factors for edema included an age greater than 60 years, no previous surgery, perilesional edema before radiosurgery, a tumor volume greater than 10 cm3, a tumor location in the anterior fossa, and a margin dose greater than 16 Gy.
Conclusions
Stereotactic radiosurgery is a safe method of treatment for meningiomas. A minimum margin dose of 12 to 16 Gy seems to represent the therapeutic window for benign meningiomas with a high tumor control rate in a mid-term follow-up period.
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Affiliation(s)
- Aurelia Kollová
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
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Abstract
Abstract
OBJECTIVE
The most important treatment options for meningiomas are microsurgery, radiotherapy, and gamma knife radiosurgery (GKRS). The efficacy of GKRS in terms of local tumor control and tumor volume (TV) reduction can best be determined by accurate analysis of changes in tumor size in pre- and post-GKRS images. In this prospective study, we set the focus on evaluating TV changes and treatment outcome of meningiomas using a quantitative volumetric follow-up protocol after GKRS.
METHODS
Consecutive patients with World Health Organization Grade I and II meningiomas were included in this study. Most patients underwent a microsurgical TV reduction before being treated with GKRS. Follow-up examinations were performed according to a standardized protocol and included magnetic resonance imaging and quantitative volumetric tumor analyses as well as thorough neurological examinations.
RESULTS
Complete follow-up data was available for 211 patients (243 tumors) with a mean age of 57.9 years. TVs ranging from 0.1 to 48.3cm3 were treated with GKRS using prescription doses ranging from 10 to 22 Gy. The achieved overall tumor control rate determined with quantitative TV analyses after GKRS was 93.4%; a mean TV reduction of 42.1% was achieved in 74.5% of all treated patients.
CONCLUSION
Results of this study show that a quantitative volumetric follow-up study of meningiomas is a useful method to demonstrate the efficacy of GKRS for meningiomas. Statistically significant TV reductions with a low rate of side effects can be achieved with GKRS.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany.
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Couldwell WT, Cole CD, Al-Mefty O. Patterns of skull base meningioma progression after failed radiosurgery. J Neurosurg 2007; 106:30-5. [PMID: 17236485 DOI: 10.3171/jns.2007.106.1.30] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Stereotactic radiosurgery has been reported to be an effective alternative to surgical removal of small to medium benign meningiomas as well as an adjuvant treatment modality to reduce the risk of tumor progression after subtotal resection. Its efficacy has been proved by excellent short-term radiosurgically demonstrated control rates, which have been reported to approach or exceed 90% in many contemporary studies involving the use of either linear accelerator–based systems or the Gamma Knife. Little is known, however, regarding the growth patterns of meningiomas that fail to stabilize after radiosurgery.
Methods
The authors report 13 cases of benign skull base meningiomas (World Health Organization Grade I) that demonstrated progression after radiosurgical treatment as a primary or an adjuvant therapy. Several tumors demonstrated rapid growth immediately after radiosurgical treatment, whereas other lesions progressed in a very delayed manner in some patients (up to 14 years after treatment). Regardless of the interval after which it occurs, tumor growth can be quite aggressive once it has begun.
Conclusions
Skull base meningioma growth can be aggressive after failed radiosurgery in some patients, and treatment failure can occur at long intervals following treatment. Special attention must be devoted to such significant occurrences given the increasing number of patients undergoing stereotactic radiosurgery for benign tumors, and careful extended (> 10 years) follow up must be undertaken in all patients after radiosurgery.
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Affiliation(s)
- William T Couldwell
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah 84132, USA.
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Yamada S, Kawai S, Yonezawa T, Masui K, Nishi N, Fujiwara K. Cervical Extradural En-plaque Meningioma-Case Report-. Neurol Med Chir (Tokyo) 2007; 47:36-9. [PMID: 17245014 DOI: 10.2176/nmc.47.36] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 22-year-old woman presented with a very rare extradural en-plaque spinal meningioma manifesting as right hemiparesis and gait disturbance. Magnetic resonance imaging revealed a well-enhanced lesion extending from the C-1 to C-5 vertebral levels, compressing the cord dorsally. Computed tomography revealed a slightly enhanced mass with calcification in the spinal canal, advancing in all directions except anteriorly. Surgery could not completely remove the part of the tumor that had progressed laterally. The histological diagnosis was cervical extradural en-plaque meningioma. Postoperatively, there was remarkable improvement in the patient's symptoms. Successful treatment of this type of tumor requires the development of a combined surgical and radiosurgical approach.
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Affiliation(s)
- Shuichi Yamada
- Department of Neurosurgery, Osaka General Medical Center, Osaka, Japan.
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Adler JR, Gibbs IC, Puataweepong P, Chang SD. Visual field preservation after multisession cyberknife radiosurgery for perioptic lesions. Neurosurgery 2006; 59:244-54; discussion 244-54. [PMID: 16883165 DOI: 10.1227/01.neu.0000223512.09115.3e] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The restricted radiation tolerance of the anterior visual pathways represents a unique challenge for ablating adjacent lesions with single-session radiosurgery. Although preliminary studies have recently demonstrated that multisession radiosurgery for selected perioptic tumors is both safe and effective, the number of patients in these clinical series was modest and the length of follow-up limited. The current retrospective study is intended to help address these shortcomings. METHODS Forty-nine consecutive patients with meningioma (n = 27), pituitary adenoma (n = 19), craniopharyngioma (n = 2), or mixed germ cell tumor (n = 1) situated within 2 mm of a "short segment" of the optic apparatus underwent multisession image-guided radiosurgery at Stanford University Medical Center. Thirty-nine of these patients had previous subtotal surgical resection, and six had previously been treated with conventional fractionated radiotherapy (6). CyberKnife radiosurgery was delivered in two to five sessions to an average tumor volume of 7.7 cm3 and a cumulative average marginal dose of 20.3 Gy. Formal visual testing and clinical examinations were performed before treatment and at follow-up intervals beginning at 6 months. RESULTS After a mean visual field follow-up of 49 months (range, 6-96 mo), vision was unchanged postradiosurgery in 38 patients, improved in eight (16%), and worse in three (6%). In each instance, visual deterioration was accompanied by tumor progression that ultimately resulted in patient death. However, one of these patients, who had a multiply recurrent adrenocorticotropic hormone-secreting pituitary adenoma, initially experienced early visual loss without significant tumor progression after both a previous course of radiotherapy and three separate sessions of radiosurgery. After a mean magnetic resonance imaging follow-up period of 46 months, tumor volume was stable or smaller in all other cases. Two patients died of unrelated nonbrain causes. CONCLUSION Multisession radiosurgery resulted in high rates of tumor control and preservation of visual function in this group of perioptic tumors. Ninety-four percent of patients retained or improved preradiosurgical vision. This intermediate-term experience reinforces the findings from earlier studies that suggested that multisession radiosurgery can be a safe and effective alternative to either surgery or fractionated radiotherapy for selected lesions immediately adjacent to short segments of the optic apparatus.
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Affiliation(s)
- John R Adler
- Department of Neurosurgery, Stanford University Medical School, Stanford, California, USA.
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Zachenhofer I, Wolfsberger S, Aichholzer M, Bertalanffy A, Roessler K, Kitz K, Knosp E. Gamma-knife radiosurgery for cranial base meningiomas: experience of tumor control, clinical course, and morbidity in a follow-up of more than 8 years. Neurosurgery 2006; 58:28-36; discussion 28-36. [PMID: 16385326 DOI: 10.1227/01.neu.0000190654.82265.a3] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Surgical resection of cranial base meningiomas is often limited owing to involvement of crucial neural structures. Within the last 2 decades Gamma Knife radiosurgery (GKRS) has gained increasing importance as an adjunct treatment after incomplete resection and as an alternative treatment to open surgery. However, reports of long-term results are still sparse. We therefore performed this study to analyze the long-term results of GKRS treatment of cranial base meningiomas, following our previously published early follow-up experience. METHODS A retrospective analysis of the medical files for Gamma Knife and surgical treatments, clinicoradiological findings, and outcome was carried out focusing on tumor control, clinical course, and morbidity. RESULTS Between 1992 and 1995, we treated 36 patients with cranial base meningiomas using GKRS (male:female ratio, 1:5; mean age, 59 yr; range, 44-89 yr). Twenty-five patients were treated with GKRS after open surgery, and 11 patients received GKRS alone. Tumor control, neurological outcomes, and adverse effects were analyzed after a long-term follow-up period (mean, 103 mo; range, 70-133 mo) and compared with our previous results after an early follow-up period (mean, 48 mo; range, 36-76 mo). Control of tumor growth was achieved in 94% of patients. Compared with the early follow-up period, the late neuroradiological effects of GKRS on cranial base meningiomas were continuing tumor shrinkage in 11 patients (33%), stable tumor size in 20 patients (64%) and tumor progression in two meningiomas (6%). The neurological status improved in 16 patients (44%), remained stable in 19 patients (52%), and deteriorated in one patient (4%). Adverse side effects of GKRS were found only during the early follow-up period. CONCLUSION Our data confirm that GKRS is not only a safe and effective treatment modality for cranial base meningiomas in short-term observation, but also in a mean long-term follow-up period of more than 8 years. Tumor shrinkage and clinical improvement also continued during the longer follow-up period.
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Affiliation(s)
- Iris Zachenhofer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
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Kreil W, Luggin J, Fuchs I, Weigl V, Eustacchio S, Papaefthymiou G. Long term experience of gamma knife radiosurgery for benign skull base meningiomas. J Neurol Neurosurg Psychiatry 2005; 76:1425-30. [PMID: 16170090 PMCID: PMC1739368 DOI: 10.1136/jnnp.2004.049213] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES As most reports on the gamma knife have related only to short or mid-term results, we decided to evaluate the effectiveness and toxicity of radiosurgical treatment for benign skull base meningiomas in 200 patients with a follow up of 5-12 years to define the role of gamma knife radiosurgery (GKRS) for basal meningiomas and to provide further data for comparison with other treatment options. METHODS In total, 99 patients were treated with a combination of microsurgical resection and GKRS. In 101 patients, GKRS was performed as the sole treatment option. Tumour volumes ranged from 0.38 to 89.8 cm3 (median 6.5 cm3), and doses of 7-25 Gy (median 12 Gy) were given to the tumour borders at covering isodose volume curves (range 20-80%, median 45%). RESULTS The actuarial progression free survival rate was 98.5% at 5 years and 97.2% at 10 years. Passing radiation induced oedema occurred in two patients (1%). The neurological status improved in 83 cases (41.5%), remained unaltered in 108 (54%), and deteriorated in 9 (4.5%). Worsening was transient in seven patients (3.5%) and unrelated to tumour or treatment in one (0.5%). Repeated microsurgical resection was performed in five patients following GKRS (2.5%). CONCLUSIONS GKRS has proved to be an effective alternative to microsurgical resection, radiotherapy, and Linac based radiosurgery for adjunctive and primary treatment of selected patients with basal meningiomas. Because of the excellent long term tumour control rate and low morbidity associated with GKRS, this treatment option should be used more frequently in the therapeutic management of benign skull base meningiomas.
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Affiliation(s)
- W Kreil
- Department of Neurosurgery, Medical University Graz, Graz, Austria.
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Ramina R, Neto MC, Fernandes YB, Aguiar PHP, de Meneses MS, Torres LFB. Meningiomas of the jugular foramen. Neurosurg Rev 2005; 29:55-60. [PMID: 16195869 DOI: 10.1007/s10143-005-0415-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2005] [Revised: 07/22/2005] [Accepted: 08/02/2005] [Indexed: 11/30/2022]
Abstract
Primary meningiomas of the jugular foramen are extremely rare. There is controversy regarding the management of these tumors. The objective of this article is to analyze the treatment and results in a series of ten cases. From a series of 107 patients that had been operated on for jugular foramen tumors between 1987 and 2005, ten had meningiomas. The clinical, histological and imaging findings, as well as the outcome of these cases, were reviewed. A high incidence of malignant or aggressive tumors (six cases) was found. Gross total resection (Simpson I and II) was achieved in five patients. Four patients with meningotheliomatous meningiomas are alive, with a mean follow-up time of 71.8 months (6.5 years). Two patients (one with anaplastic type and one with papillary type) died in the immediate postoperative period. Four patients (two with papillary type, one with microcystic type and one with anaplastic type) died because of disease progression, with a mean survival time of 35 months. Radical removal of benign jugular foramen meningiomas is possible. The incidence of postoperative deficit of cranial nerves is higher than in other benign tumors of the jugular foramen. A high incidence of aggressive (malignant) tumors was observed in this series.
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Affiliation(s)
- Ricardo Ramina
- Department of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, Brazil.
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Noël G, Bollet MA, Calugaru V, Feuvret L, Haie-Meder C, Dhermain F, Ferrand R, Boisserie G, Beaudré A, Mazeron JJ, Habrand JL. Functional outcome of patients with benign meningioma treated by 3D conformal irradiation with a combination of photons and protons. Int J Radiat Oncol Biol Phys 2005; 62:1412-22. [PMID: 16029801 DOI: 10.1016/j.ijrobp.2004.12.048] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Revised: 12/28/2004] [Accepted: 12/29/2004] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate efficacy and tolerance of external fractionated combination of photon and proton radiation therapy (RT) for intracranial benign meningiomas. METHODS AND MATERIALS Between 1994 and 2002, 51 patients with intracranial meningiomas of the base of the skull were treated with a combination of photon and proton RT. Median total dose was 60.6 cobalt Gy equivalent (54-64). One hundred eight eye-related symptoms were collected; 80 other symptoms were noted and followed up. RESULTS Mean follow-up was 25.4 months. Acute tolerance was excellent. Out of the 108 eye-related symptoms, 106 (96%) were evaluated. Improvements were reported for 73 (68.8%) of them. Out of the 88 other miscellaneous symptoms, 81 (92%) were evaluated. Improvements were reported in 54 cases (67%). Median time to improvement ranged from 1 to 24 months after completion of the radiotherapy, depending on the symptom. We did not observe any worsening of primary clinical signs. Radiologically, 1 patient relapsed 4 months after the end of irradiation. Pathology revealed a malignant (Grade 3) transformation of the initial Grade 1 meningioma. Four-year local control and overall survival rates were, respectively, 98% and 100%. Stabilization of the tumor was observed in 38 cases (72%), volume reduction in 10 cases (20%), and intratumor necrosis in 3 cases. Two patients complained of Grade 3 side effects: 1 unilateral hearing loss requiring aid and 1 case of complete pituitary deficiency. CONCLUSION These results stressed the clinical efficacy of fractionated-associated photon-proton RT in the treatment of meningiomas, especially on cranial nerve palsies, without severe toxicity in almost all patients.
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Altinors N, Caner H, Bavbek M, Erdogan B, Atalay B, Calisaneller T, Cekinmez M. Problems in the management of intracranial meningiomas. J INVEST SURG 2005; 17:283-9. [PMID: 15385261 DOI: 10.1080/08941930490502853] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Meningiomas account for approximately 15-20% of all brain tumors, and are the most common benign intracranial tumor. These neoplasms develop from cap cells in the arachnoidea; thus, they can be found anywhere that dura mater exists. Meningiomas are usually diagnosed in middle age, and are significantly more frequent in females than in males. Atypical and anaplastic malignant forms also exist. Some types of meningiomas are difficult to manage and require special considerations. The first-line therapy for meningioma is surgery aimed at total excision; however, limitations of surgery must be fully evaluated in order to achieve better results. Conventional radiotherapy and gamma-knife radiosurgery can be used as adjuvant therapeutic modalities under certain conditions. The issues that we consider important in the management of intracranial meningiomas can be discussed under the headings of diagnosis, surgery, multiplicity, pathology, and recurrence.
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Affiliation(s)
- Nur Altinors
- Department of Neurosurgery, Baskent University Faculty of Medicine, Ankara, Turkey.
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