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Eekers DBP, Zegers CML, Ahmed KA, Amelio D, Gupta T, Harrabi SB, Kazda T, Scartoni D, Seidel C, Shih HA, Minniti G. Controversies in neuro-oncology: Focal proton versus photon radiation therapy for adult brain tumors. Neurooncol Pract 2024; 11:369-382. [PMID: 39006517 PMCID: PMC11241386 DOI: 10.1093/nop/npae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Radiation therapy (RT) plays a fundamental role in the treatment of malignant and benign brain tumors. Current state-of-the-art photon- and proton-based RT combines more conformal dose distribution of target volumes and accurate dose delivery while limiting the adverse radiation effects. PubMed was systematically searched from from 2000 to October 2023 to identify studies reporting outcomes related to treatment of central nervous system (CNS)/skull base tumors with PT in adults. Several studies have demonstrated that proton therapy (PT) provides a reduced dose to healthy brain parenchyma compared with photon-based (xRT) radiation techniques. However, whether dosimetric advantages translate into superior clinical outcomes for different adult brain tumors remains an open question. This review aims at critically reviewing the recent studies on PT in adult patients with brain tumors, including glioma, meningiomas, and chordomas, to explore its potential benefits compared with xRT.
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Affiliation(s)
- Danielle B P Eekers
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW-School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Catharina M L Zegers
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW-School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Kamran A Ahmed
- Departments of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Dante Amelio
- Trento Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Tejpal Gupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Semi Ben Harrabi
- Department of Radiation Oncology, Heidelberg Ion Beam Therapy Center (HIT), University Hospital Heidelberg, Heidelberg, Germany
| | - Tomas Kazda
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University and Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Daniele Scartoni
- Trento Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Clemens Seidel
- Comprehensive Cancer Center Central Germany, Leipzig, Germany
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giuseppe Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
- IRCCS Neuromed, Pozzilli IS, Italy
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Kotecha R, La Rosa A, Mehta MP. How proton therapy fits into the management of adult intracranial tumors. Neuro Oncol 2024; 26:S26-S45. [PMID: 38437667 PMCID: PMC10911801 DOI: 10.1093/neuonc/noad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Intracranial tumors include a challenging array of primary and secondary parenchymal and extra-axial tumors which cause neurologic morbidity consequential to location, disease extent, and proximity to critical neurologic structures. Radiotherapy can be used in the definitive, adjuvant, or salvage setting either with curative or palliative intent. Proton therapy (PT) is a promising advance due to dosimetric advantages compared to conventional photon radiotherapy with regards to normal tissue sparing, as well as distinct physical properties, which yield radiobiologic benefits. In this review, the principles of efficacy and safety of PT for a variety of intracranial tumors are discussed, drawing upon case series, retrospective and prospective cohort studies, and randomized clinical trials. This manuscript explores the potential advantages of PT, including reduced acute and late treatment-related side effects and improved quality of life. The objective is to provide a comprehensive review of the current evidence and clinical outcomes of PT. Given the lack of consensus and directives for its utilization in patients with intracranial tumors, we aim to provide a guide for its judicious use in clinical practice.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Department of Translational Medicine, Hebert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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Piperno G, Ferrari A, Volpe S, Cattani F, Zaffaroni M, Comi S, Pansini F, Bergamaschi L, Mazzola GC, Ceci F, Colandrea M, Petralia G, Orecchia R, Jereczek-Fossa BA, Alterio D. Hypofractionated proton therapy for benign tumors of the central nervous system: A systematic review of the literature. Crit Rev Oncol Hematol 2023; 191:104114. [PMID: 37683814 DOI: 10.1016/j.critrevonc.2023.104114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/26/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
AIMS Aim of the present analysis was to report results of a systematic review of the literature in the setting of patients treated with hypoF PT for benign lesions of the central nervous system (CNS). METHODS The methodology complied with the PRISMA recommendations. PubMed, EMBASE and Scopus databases were interrogated in September 2022. RESULTS Twelve papers have been selected including patients treated for base of the skull meningiomas (6 papers), vestibular schwannoma (3 papers) and pituitary adenomas (3 papers). Clinical outcomes were evaluated with both radiologic images and clinical parameters. Long-term toxicity was reported in all but one series with an incidence ranging from 2 % to 7 % in patients treated for base of skull meningioma and 1-9 % for schwannoma. CONCLUSIONS HypoF PT is a safe and effective treatment in selected benign tumors of the CNS. Further dosimetric and clinical comparisons are required to better refine the patients' selection criteria.
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Affiliation(s)
- Gaia Piperno
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Annamaria Ferrari
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Volpe
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Federica Cattani
- Unit of Medical Physics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Comi
- Unit of Medical Physics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Floriana Pansini
- Unit of Medical Physics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Luca Bergamaschi
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | | | - Francesco Ceci
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Division of Nuclear Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Marzia Colandrea
- Precision Imaging and Research Unit, Department of Medical Imaging and Radiation Sciences, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Petralia
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; Precision Imaging and Research Unit, Department of Medical Imaging and Radiation Sciences, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Daniela Alterio
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
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Iannalfi A, Riva G, Ciccone L, Orlandi E. The role of particle radiotherapy in the treatment of skull base tumors. Front Oncol 2023; 13:1161752. [PMID: 37350949 PMCID: PMC10283010 DOI: 10.3389/fonc.2023.1161752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/19/2023] [Indexed: 06/24/2023] Open
Abstract
The skull base is an anatomically and functionally critical area surrounded by vital structures such as the brainstem, the spinal cord, blood vessels, and cranial nerves. Due to this complexity, management of skull base tumors requires a multidisciplinary approach involving a team of specialists such as neurosurgeons, otorhinolaryngologists, radiation oncologists, endocrinologists, and medical oncologists. In the case of pediatric patients, cancer management should be performed by a team of pediatric-trained specialists. Radiation therapy may be used alone or in combination with surgery to treat skull base tumors. There are two main types of radiation therapy: photon therapy and particle therapy. Particle radiotherapy uses charged particles (protons or carbon ions) that, due to their peculiar physical properties, permit precise targeting of the tumor with minimal healthy tissue exposure. These characteristics allow for minimizing the potential long-term effects of radiation exposure in terms of neurocognitive impairments, preserving quality of life, and reducing the risk of radio-induced cancer. For these reasons, in children, adolescents, and young adults, proton therapy should be an elective option when available. In radioresistant tumors such as chordomas and sarcomas and previously irradiated recurrent tumors, particle therapy permits the delivery of high biologically effective doses with low, or however acceptable, toxicity. Carbon ion therapy has peculiar and favorable radiobiological characteristics to overcome radioresistance features. In low-grade tumors, proton therapy should be considered in challenging cases due to tumor volume and involvement of critical neural structures. However, particle radiotherapy is still relatively new, and more research is needed to fully understand its effects. Additionally, the availability of particle therapy is limited as it requires specialized equipment and expertise. The purpose of this manuscript is to review the available literature regarding the role of particle radiotherapy in the treatment of skull base tumors.
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Flechl B, Konrath L, Hug E, Fossati P, Lütgendorf-Caucig C, Achtaewa M, Pelak M, Georg P. Meningioma WHO I with involvement of the optical structures-does proton therapy lead to changes in quality of life with regard to subjective visual performance? Strahlenther Onkol 2023; 199:404-411. [PMID: 36471065 DOI: 10.1007/s00066-022-02024-y] [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: 06/14/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In addition to local tumor control, the aim of any curative radio-oncological treatment is to maintain quality of life. In the treatment of patients with meningioma with a close relationship to optical structures, the preservation of visual performance is a particular challenge. Use of proton therapy can reduce the dose burden to organs at risk immediately adjacent to the tumor. The aim of this study was to score the subjective assessment of visual performance in patients with meningioma involving the optical structures before and after proton therapy. METHODS All proton-treated patients with meningioma WHO I whose planning target volumes (PTV) included parts of the optic nerve and/or chiasm were included in this study. Subjective assessment of visual performance was evaluated using the Visual Disorder Scale (VDS) of the EORTC QLQ-BN20 questionnaire. This scale includes values from 0 to 100, whereby high values reflect a high degree of subjective symptom burden and thus subjective visual impairment. The visual acuity in externally performed eye tests at baseline and follow-ups (FU) was also evaluated. The timepoints for testing were before the start of radiotherapy, at the end of treatment, and 3, 6, 12, and 24 months in FU (times t1-t6). All patients with at least the first annual postradiation FU at the time of the evaluation were included. The correlation between VDS changes and potential influencing factors such as previous therapies, dosimetric data, initial tumor volume, and tumor shrinkage 1 year after treatment was assessed. RESULTS A total of 56 patients (45 female/11 male) aged 24-82 years (mean ± SD = 53.9 ± 13.3) treated between March 2017 and September 2019 were included in the analysis. The prescription dose was 54.0 Gy (RBE) with active scanned proton therapy. The mean/D2% dose ± SD for the optic chiasm and ipsilateral optic nerve was 43.4 ± 8.9 Gy (RBE)/49.9 ± 7.1 Gy (RBE) and 35.6 ± 11.7 Gy (RBE)/51.7 ± 4.8 Gy (RBE); the mean/D2% dose ± SD of the contralateral optic nerve was 18.8 ± 12.1 Gy (RBE)/42.4 ± 14.6 Gy (RBE), respectively. A total of 302 data collections were available (t1/t2/t3/t4/t5/t6: n = 56/56/48/56/52/34). Median observation time was 23.6 months. Mean symptom burden decreased over time (mean VDS: t1 29.8 ± 27.9; t2 25.0 ± 27.9; t3 21.8 ± 26.0; t4 22.2 ± 26.0; t5 21.4 ± 26.2; t6 17.3 ± 23.6) with statistically significant improvement at 3‑ and 6‑month FU as well as 1 year after proton therapy (p = 0.0205; p = 0.0187; p = 0.0054). Objective eye tests available in 41/52 patients confirm the trend towards improved visual acuity (97.5% stable/improved until 24-month FU). However, no potential predictor for VDS changes was revealed. CONCLUSION Proton treatment of patients with meningioma WHO I with involvement of optical structures does not impair subjective visual performance. After treatment, there is a significant improvement in perceived visual performance.
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Affiliation(s)
- Birgit Flechl
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
| | - Lisa Konrath
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
| | - Eugen Hug
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
| | - Piero Fossati
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
| | | | - Milana Achtaewa
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
| | - Maciej Pelak
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
| | - Petra Georg
- EBG MedAustron GmbH, Marie-Curie-Str. 5, 2700, Wiener Neustadt, Austria
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Gong X, Ding J, Knisely JPS, Wang E, Pan L, Wang B, Zhang N, Wu H, Dai J, Yu T, Tang X. Dose-staged Gamma Knife radiosurgery for meningiomas: A retrospective study in a single center. Front Neurol 2022; 13:893480. [PMID: 36313491 PMCID: PMC9606413 DOI: 10.3389/fneur.2022.893480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThis study aimed to study the efficiency and safety of a dose-staged Gamma Knife radiosurgery strategy for large meningiomas or meningiomas close to important nerve structures.MethodsThis study evaluates the outcome of a prospectively accrued series of 71 consecutive patients with meningiomas treated with staged dose-fractionated Gamma Knife radiosurgery. The average peripheral doses for the first and second fractions were 9.0 ± 0.9 Gy (8–12 Gy) and 8.6 ± 0.7 Gy (range, 7–10 Gy), respectively. The interval between fractions was 6.1 ± 1.9 months (range, 3–12 months). The median follow-up time was 36 months (12–96 months).ResultsDuring the follow-up period after the second fraction, 97.2% achieved tumor control in our series. A total of 2 patients exhibited local recurrence at 30 and 60 months after the second fraction, respectively. No treatment-related complications or new long-term neurological dysfunctions were reported. MRIs observed slightly or moderately increased peritumoral edema in six patients, but no specific neurological complaints are attributed to this finding.ConclusionThis study investigates the efficiency and safety of dose-staged Gamma Knife radiosurgery as an alternative option for meningiomas that were large in volume, adjacent to crucial structures, or in patients with contraindications to craniotomy.
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Affiliation(s)
- Xiu Gong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianbo Ding
- Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
- Department of Neurosurgery, Gamma Knife Center of Huashan Hospital, Shanghai, China
- *Correspondence: Jianbo Ding
| | - Jonathan P. S. Knisely
- Department of Radiation Oncology, Weill Cornell Medicine and New York-Presbyterian Hospital, New York, NY, United States
| | - Enmin Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Pan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Binjiang Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Nan Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hanfeng Wu
- Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
- Department of Neurosurgery, Gamma Knife Center of Huashan Hospital, Shanghai, China
| | - Jiazhong Dai
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tonggang Yu
- Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
- Department of Neurosurgery, Gamma Knife Center of Huashan Hospital, Shanghai, China
| | - Xuqun Tang
- Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
- Department of Neurosurgery, Gamma Knife Center of Huashan Hospital, Shanghai, China
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Ekinci F, Bostanci E, Güzel MS, Dagli O. Effect of different embolization materials on proton beam stereotactic radiosurgery Arteriovenous Malformation dose distributions using the Monte Carlo simulation code. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2022. [DOI: 10.1016/j.jrras.2022.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Corniola MV, Meling TR. Management of Recurrent Meningiomas: State of the Art and Perspectives. Cancers (Basel) 2022; 14:cancers14163995. [PMID: 36010988 PMCID: PMC9406695 DOI: 10.3390/cancers14163995] [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: 07/24/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Intracranial meningiomas account for 30% to 40% of the primary lesions of the central nervous system. Surgery is the mainstay treatment whenever symptoms related to an intra-cranial meningioma are encountered. However, the management of recurrences after initial surgery, which are not uncommon, is still a matter of debate. Here, we present the alternatives described in the management of meningioma recurrence (radiotherapy, stereotaxic radiosurgery, protontherapy, and chemotherapy, among others). Their overall results are compared to surgery and future perspectives are presented. Abstract Background: While meningiomas often recur over time, the natural history of repeated recurrences and their management are not well described. Should recurrence occur, repeat surgery and/or use of adjuvant therapeutic options may be necessary. Here, we summarize current practice when it comes to meningioma recurrence after initial surgical management. Methods: A total of N = 89 articles were screened. N = 41 articles met the inclusion criteria and N = 16 articles failed to assess management of meningioma recurrence. Finally, N = 24 articles were included in our review. Results: The articles were distributed as follows: studies on chemotherapy (N = 14), radiotherapy, protontherapy, and stereotaxic radiosurgery (N = 6), boron-neutron capture therapy (N = 2) and surgery (N = 3). No study seems to provide serious alternatives to surgery in terms of progression-free and overall survival. Recurrence can occur long after the initial surgery and also affects WHO grade 1 meningiomas, even after initial gross total resection at first surgery, emphasizing the need for a long-term and comprehensive follow-up. Conclusions: Surgery still seems to be the state-of-the-art management when it comes to meningioma recurrence, since none of the non-surgical alternatives show promising results in terms of progression-free and overall survival.
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Affiliation(s)
- Marco Vincenzo Corniola
- Service de Neurochirurgie, Pôle des Neurosciences, Centre Hospitalier Universitaire de Rennes, 35000 Rennes, France
- Faculté de Médecine, Université de Rennes 1, 35000 Rennes, France
- Faculté de Médecine, Université de Genève, 1205 Geneve, Switzerland
- Laboratoire du Traitement de Signal, Unité Médicis, INSERM UMR 1099 LTSI, Université de Rennes 1, 35000 Rennes, France
| | - Torstein R. Meling
- Faculté de Médecine, Université de Genève, 1205 Geneve, Switzerland
- Department of Neurosurgery, Geneva University Hospitals, 1205 Geneva, Switzerland
- Besta NeuroSim Center, Fondazione IRCCS, Istituto Neurologico Carlo Basta, 20133 Milano, Italy
- Correspondence:
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Deraniyagala R, Ding X, Alonso-Basanta M, Li T, Rong Y. It is beneficial to invest resources to implement proton intracranial SRS. J Appl Clin Med Phys 2022; 23:e13701. [PMID: 35713887 PMCID: PMC9278676 DOI: 10.1002/acm2.13701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Rohan Deraniyagala
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Xuanfeng Ding
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Taoran Li
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Investigation of the effects of the step size of Geant4 electromagnetic physics on the depth dose simulation of a small field proton beam. Radiat Phys Chem Oxf Engl 1993 2022. [DOI: 10.1016/j.radphyschem.2022.110050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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The Role of Hypofractionation in Proton Therapy. Cancers (Basel) 2022; 14:cancers14092271. [PMID: 35565400 PMCID: PMC9104796 DOI: 10.3390/cancers14092271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 12/07/2022] Open
Abstract
Hypofractionated radiotherapy is an attractive approach for minimizing patient burden and treatment cost. Technological advancements in external beam radiotherapy (EBRT) delivery and image guidance have resulted in improved targeting and conformality of the absorbed dose to the disease and a reduction in dose to healthy tissue. These advances in EBRT have led to an increasing adoption and interest in hypofractionation. Furthermore, for many treatment sites, proton beam therapy (PBT) provides an improved absorbed dose distribution compared to X-ray (photon) EBRT. In the past 10 years there has been a notable increase in reported clinical data involving hypofractionation with PBT, reflecting the interest in this treatment approach. This review will discuss the reported clinical data and radiobiology of hypofractionated PBT. Over 50 published manuscripts reporting clinical results involving hypofractionation and PBT were included in this review, ~90% of which were published since 2010. The most common treatment regions reported were prostate, lung and liver, making over 70% of the reported results. Many of the reported clinical data indicate that hypofractionated PBT can be well tolerated, however future clinical trials are still needed to determine the optimal fractionation regime.
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Radiation therapy for atypical and anaplastic meningiomas: an overview of current results and controversial issues. Neurosurg Rev 2022; 45:3019-3033. [PMID: 35665867 PMCID: PMC9492595 DOI: 10.1007/s10143-022-01806-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 02/03/2023]
Abstract
Meningiomas are the most common intracranial tumors. Most meningiomas are WHO grade 1 tumors whereas less than one-quarter of all meningiomas are classified as atypical (WHO grade 2) and anaplastic (WHO grade 3) tumors, based on local invasiveness and cellular features of atypia. Surgical resection remains the cornerstone of meningioma therapy and represents the definitive treatment for the majority of patients; however, grade 2 and grade 3 meningiomas display more aggressive behavior and are difficult to treat. Several retrospective series have shown the efficacy and safety of postoperative adjuvant external beam radiation therapy (RT) for patients with atypical and anaplastic meningiomas. More recently, two phase II prospective trials by the Radiation Therapy Oncology Group (RTOG 0539) and the European Organisation for Research and Treatment of Cancer (EORTC 2042) have confirmed the potential benefits of fractionated RT for patients with intermediate and high-risk meningiomas; however, several issues remain a matter of debate. Controversial topics include the timing of radiation treatment in patients with totally resected atypical meningiomas, the optimal radiation technique, dose and fractionation, and treatment planning/target delineation. Ongoing randomized trials are evaluating the efficacy of early adjuvant RT over observation in patients undergoing gross total resection.
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Champeaux-Depond C, Weller J. Outcome After Protontherapy for Progression or Recurrence of Surgically Treated Meningioma. Brain Tumor Res Treat 2021; 9:46-57. [PMID: 34725984 PMCID: PMC8561229 DOI: 10.14791/btrt.2021.9.e9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 11/20/2022] Open
Abstract
Background To assess the outcome after meningioma surgery and protontherapy (PT). Methods We processed the French Système National des Données de Santé database to retrieve appropriate cases of meningiomas operated and irradiated between 2008 and 2017. Survival methods were implemented. Results One hundred ninety-three patients who received PT after meningioma surgery over a 10-year period were identified. Of the 193 patients, 75.6% were female. Median age at surgery was 50 years (interquartile range [IQR] 41–62). The median number of PT fractions was 31 (IQR 30–39) given over a median duration of 52 days (IQR 44–69). Fourteen patients (7.3%) also received photon radiotherapy and six patients (3.1%) stereotactic radiosurgery. Median follow-up was 4.4 years (IQR 3.86–4.71). Five-year progression-free survival (PFS) rate was 69% (95% confidence interval [CI] 62.1–76.6). For benign, atypical, and malignant meningioma, 5-year PFS rates were 71.5% (95% CI 64.4–79.4), 55.6% (95% CI 32.5–95), and 35.6% (95% CI 12.8–98.9), respectively (p<0.01). In the adjusted regression, tumour location (hazard ratio [HR]=0.1, 95% CI 0.05–0.22, p<0.001), aggressive meningioma (HR=2.26, 95% CI 1.1–4.66, p=0.027), and the need of cerebrospinal fluid (CSF) insertion for hydrocephalus (HR=3.51, 95% CI 1.32–9.31, p=0.012) remained significantly associated to the PFS. All grades considered, 5-year overall survival (OS) rates was 89.7% (95% CI 84.6–95.1). For benign, atypical, and malignant meningioma, 5-year OS rates were 93% (95% CI 88.7–97.4), 76.4% (95% CI 51.4–100), and 44.4% (95% CI 16.7–100), respectively (p<0.01). In the multivariable regression, an older age above 70 years (HR=5.95, 95% CI 2.09–16.89, p<0.001) associated to a high level of comorbidities (HR=5.31, 95% CI 1.43–19.78, p=0.013) and a malignant meningioma (HR=5.68, 95% CI 1.54–20.94, p=0.009) remained significantly associated to a reduced OS. Conclusion Five-year PFS and OS after meningioma surgery and PT is favourable but impaired for older patients with high level of morbidities, tumour of the convexity, malignant histopathology and for those requiring CSF shunting. Further inclusion and prolonged follow-up is required to assess other predictors such as sex, tumour volume, or given dose.
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Affiliation(s)
- Charles Champeaux-Depond
- Department of Neurosurgery, Lariboisière Hospital, Paris, France.,INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), ECSTRRA Team, Université de Paris, Paris, France.
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14
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Li JY, Li JW, Jin YC, Li MX, Guo LP, Bing ZT, Zhang QN, Bai F, Wang XH, Li XX, Yang KH. The Efficacy and Safety of Carbon Ion Radiotherapy for Meningiomas: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:620534. [PMID: 34113557 PMCID: PMC8185343 DOI: 10.3389/fonc.2021.620534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/27/2021] [Indexed: 11/30/2022] Open
Abstract
Objective The purpose of this systematic review and meta-analysis is to evaluate the efficacy and safety of carbon ion radiotherapy (CI-RT) in improving meningioma by comparing photon and protons radiotherapy. Methods A comprehensive search for relevant studies published until March 17, 2021, was conducted in PubMed, the Cochrane Library, Chinese Biomedical Literature Database and EMBASE. Statistical analyses were performed with R 4.0.3. Results We identified 396 studies, of which 18 studies involving 985 participants were included. Except for one low quality study, the quality of the included studies was found to be either moderate or high quality. The analyses conducted according random effects model indicated that the 1-year overall survival rate (OS) of benign and non-benign meningiomas after the CI-RT treatment was 99% (95%CL=.91-1.00, I2 = 0%). The overall average 5-year OS for meningiomas was 72% (95%CL=0.52-0.86, I2 = 35%), not as effective as proton radiotherapy (PR-RT) 85% (95%CL=.72-.93, I2 = 73, Q=4.17, df=2, p=.12). Additionally, 5-year OS of atypical meningiomas (81%) was found to be significantly higher than anaplastic meningiomas (52%). The 10-year OS after CI-RT of patients with mixed grade meningioma was 91% (95%CL=.75-.97, I2 = 73%). The 15-year OS after CI-RT 87% (95%CL=.11-1.00) or PR-RT 87% (95%CL=.23-.99, I2 = 79%) were the same (Q=0, df=1, p=.99). After undergoing CI-RT for 3 and 5 years, the LC for benign meningioma was 100% and 88%, respectively, while the 2-year LC of non-benign meningiomas (atypical/anaplastic) was 33%. Headache, sensory impairment, cognitive impairment, and hearing impairment were found to be the most common adverse reactions, with individual incidences of 19.4%, 23.7%, 9.1%, and 9.1%, respectively. Conclusion CI-RT is a rapidly developing technique that has been proven to be an effective treatment against meningioma. The efficacy and safety of CI-RT for meningiomas were similar to those of PR-RT, better than photon radiotherapy (PH-RT). However, there is a need for more prospective trials in the future that can help provide more supportive evidence.
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Affiliation(s)
- Jie-Yun Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Jing-Wen Li
- Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Yuan-Chang Jin
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China.,Institute of Modern Physics, Chinese Academy of Sciences, Beijing, China.,Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Mei-Xuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Li-Ping Guo
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Zhi-Tong Bing
- Institute of Modern Physics, Chinese Academy of Sciences, Beijing, China
| | - Qiu-Ning Zhang
- Institute of Modern Physics, Chinese Academy of Sciences, Beijing, China.,Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Fei Bai
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China.,National Health Commission Medical Management Center, Beijing, China
| | - Xiao-Hu Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China.,Institute of Modern Physics, Chinese Academy of Sciences, Beijing, China.,Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Xiu-Xia Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Ke-Hu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Health Technology Assessment Center of Lanzhou University, School of Public Health, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
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Sato H, Mizumoto M, Okumura T, Sakurai H, Sakamoto N, Akutsu H, Ishikawa E, Tsuboi K. Long-term outcomes of patients with unresectable benign meningioma treated with proton beam therapy. JOURNAL OF RADIATION RESEARCH 2021; 62:427-437. [PMID: 33855438 PMCID: PMC8127652 DOI: 10.1093/jrr/rrab017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Indexed: 05/07/2023]
Abstract
This study aimed to evaluate the long-term efficacy of proton beam therapy (PBT) for unresectable benign meningiomas at the University of Tsukuba, Japan. From 1986-1998, 10 patients were treated at the Particle Radiation Medical Science Center (PRMSC) with a relative biological effectiveness (RBE) value of 1.0 using an accelerator built for physics experiments. The total dose was compensated with an X-ray in three patients. Following that, from 2002-2017, 17 patients were treated with a RBE value of 1.1 at the Proton Medical Research Center (PMRC) which was built for medical use. At the PRMSC, the total dose ranged from 50.4-66 Gy (median: 54 Gy). During the follow-up, which lasted between 3.8 and 31.6 years (median: 25.1 years), the 5-, 10-, 15-, 20- and 30-year local control rates were 100%, and the 5-, 10-, 15-, 20- and 30-year survival rates were 90, 80, 70, 70 and 36%, respectively. One patient died of brainstem radiation necrosis 5.1 years after PBT. At PMRC, the total dose ranged from 45.0-61.2 GyE, with a median of 50.4 GyE. During the follow-up, which lasted between 3 and 17 years with a median of 10.5 years, the 5-, 10- and 15-year local control rates were 94.1%, and the 5-, 10- and 15-year survival rates were 100, 100 and 88.9%, respectively. Neither malignant transformation nor secondary malignancy was observed, indicating that fractionated PBT may be effective and safely control benign unresectable meningioma even for the lifelong period of time.
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Affiliation(s)
- Hiroshige Sato
- Biomedical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennohdai, Tsukuba, Ibaraki 305-8575, Japan
| | - Masashi Mizumoto
- Department of Radiation Oncology, Proton Beam Therapy Center, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology, Proton Beam Therapy Center, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, Proton Beam Therapy Center, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - Noriaki Sakamoto
- Department of Diagnostic Pathology, Faculty of Medicine, University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - Koji Tsuboi
- Tumor Therapy Center, Tsukuba Central Hospital, 1589-3 Kashiwada, Ushiku, Ibaraki 300-1211, Japan
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16
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Zou W, Kurtz G, Nakib M, Burgdorf B, Alp M, Li T, Lustig R, Xiao Y, Dong L, Kassaee A, Alonso-Basanta M. A Probability-Based Investigation on the Setup Robustness of Pencil-beam Proton Radiation Therapy for Skull-Base Meningioma. Int J Part Ther 2021; 7:34-45. [PMID: 33604414 PMCID: PMC7886272 DOI: 10.14338/ijpt-20-00009.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 10/19/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction The intracranial skull-base meningioma is in proximity to multiple critical organs and heterogeneous tissues. Steep dose gradients often result from avoiding critical organs in proton treatment plans. Dose uncertainties arising from setup errors under image-guided radiation therapy are worthy of evaluation. Patients and Methods Fourteen patients with skull-base meningioma were retrospectively identified and planned with proton pencil beam scanning (PBS) single-field uniform dose (SFUD) and multifield optimization (MFO) techniques. The setup uncertainties were assigned a probability model on the basis of prior published data. The impact on the dose distribution from nominal 1-mm and large, less probable setup errors, as well as the cumulative effect, was analyzed. The robustness of SFUD and MFO planning techniques in these scenarios was discussed. Results The target coverage was reduced and the plan dose hot spot increased by all setup uncertainty scenarios regardless of the planning techniques. For 1 mm nominal shifts, the deviations in clinical target volume (CTV) coverage D99% was -11 ± 52 cGy and -45 ± 147 cGy for SFUD and MFO plans. The setup uncertainties affected the organ at risk (OAR) dose both positively and negatively. The statistical average of the setup uncertainties had <100 cGy impact on the plan qualities for all patients. The cumulative deviations in CTV D95% were 1 ± 34 cGy and -7 ± 18 cGy for SFUD and MFO plans. Conclusion It is important to understand the impact of setup uncertainties on skull-base meningioma, as the tumor target has complex shape and is in proximity to multiple critical organs. Our work evaluated the setup uncertainty based on its probability distribution and evaluated the dosimetric consequences. In general, the SFUD plans demonstrated more robustness than the MFO plans in target coverages and brainstem dose. The probability-weighted overall effect on the dose distribution is small compared to the dosimetric shift during single fraction.
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Affiliation(s)
- Wei Zou
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Goldie Kurtz
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mayisha Nakib
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan Burgdorf
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Murat Alp
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Taoran Li
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Lustig
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ying Xiao
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lei Dong
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alireza Kassaee
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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17
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Weber DC, Bizzocchi N, Bolsi A, Jenkinson MD. Proton Therapy for Intracranial Meningioma for the Treatment of Primary/Recurrent Disease Including Re-Irradiation. Front Oncol 2020; 10:558845. [PMID: 33381447 PMCID: PMC7769250 DOI: 10.3389/fonc.2020.558845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/28/2020] [Indexed: 01/14/2023] Open
Abstract
Meningeal tumors represent approximately 10-25% of primary brain tumors and occur usually in elderly female patients. Most meningiomas are benign (80-85%) and for symptomatic and/or large tumors, surgery, with or without radiation therapy (RT), has been long established as an effective means of local tumor control. RT can be delivered to inoperable lesions or to those with non-benign histology and for Simpson I-III and IV-V resection. RT can be delivered with photons or particles (protons or carbon ions) in stereotactic or non-stereotactic conditions. Particle therapy delivered for these tumors uses the physical properties of charged carbon ions or protons to spare normal brain tissue (i.e. Bragg peak), with or without or a dose-escalation paradigm for non-benign lesions. PT can substantially decrease the dose delivered to the non-target brain tissues, including but not limited to the hippocampi, optic apparatus or cochlea. Only a limited number of meningioma patients have been treated with PT in the adjuvant or recurrent setting, as well as for inoperable lesions with pencil beam scanning and with protons only. Approximately 500 patients with image-defined or WHO grade I meningioma have been treated with protons. The reported outcome, usually 5-year local tumor control, ranges from 85 to 99% (median, 96%). For WHO grade II or III patients, the outcome of only 97 patients has been published, reporting a median tumor local control rate of 52% (range, 38-71.1). Only 24 recurring patients treated previously with photon radiotherapy and re-treated with PT were reported. The clinical outcome of these challenging patients seems interesting, provided that they presented initially with benign tumors, are not in the elderly category and have been treated previously with conventional radiation dose of photons. Overall, the number of meningioma patients treated or-re-irradiated with this treatment modality is small and the clinical evidence level is somewhat low (i.e. 3b-5). In this review, we detail the results of upfront PT delivered to patients with meningioma in the adjuvant setting and for inoperable tumors. The outcome of meningioma patients treated with this radiation modality for recurrent tumors, with or without previous RT, will also be reviewed.
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Affiliation(s)
- Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland.,Radiation Oncology Department, University Hospital Zürich, Zürich, Switzerland.,Radiation Oncology Department, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Nicola Bizzocchi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.,Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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18
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Moderately Hypofractionated Radiation for Benign Meningiomas and Schwannomas: A Report of 70 Patients Treated Between 2008 and 2018. Adv Radiat Oncol 2020; 5:1147-1151. [PMID: 33305075 PMCID: PMC7718549 DOI: 10.1016/j.adro.2020.09.009] [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: 06/22/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Radiosurgery and fractionated intensity modulated radiation therapy (IMRT) are effective treatment modalities for meningiomas and schwannomas. Although fractionated IMRT yields favorable tumor control, daily treatments for 5 to 6 weeks can be burdensome for patients and health care systems. Thus, hypofractionated radiation may be a reasonable alternative. The purpose of this study was to review the results of patients with benign meningiomas or schwannomas treated at our institution with moderately hypofractionated IMRT. Methods and Materials After institutional review board approval, patients treated at a single academic institution between 2008 and 2018 with a primary diagnosis of either meningioma or schwannoma and who received 30 Gy at 3 Gy per fraction were identified. Patient and tumor characteristics, as well as follow-up documentation, were reviewed. Tumor progression was determined by reviewing patient imaging and provider notations. Results From 2008 to 2018, 70 patients with either meningioma or schwannoma were treated to 30 Gy. The median patient age was 73 years (range, 43-92 years). At the median follow up of 3.2 years, the local control was 92.9%. Two patients (2.9%) had disease progression, which occurred at 9.6 and 6.6 years after treatment. One patient developed asymptomatic radiographic changes consistent with radiation necrosis, which resolved without intervention. All patients completed the prescribed course without interruption. The mean tumor volume was 18.9 cm3, median volume was 36.6 cm3 (range, 3.4-245.5 cm3), and tumor volume was not associated with recurrence risk. Both tumors with progression were schwannomas. Conclusions Hypofractionated radiation with 30 Gy at 3 Gy per fraction is an effective, convenient, and well-tolerated alternative for patients with benign meningiomas or schwannomas. Modest hypofractionation provided durable control for a wide range of tumor volumes and should be considered for patients with a limited life expectancy or those unable to receive a more extended fractionated radiation therapy course.
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19
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Vogel J, Carmona R, Ainsley CG, Lustig RA. The Promise of Proton Therapy for Central Nervous System Malignancies. Neurosurgery 2020; 84:1000-1010. [PMID: 30476191 DOI: 10.1093/neuros/nyy454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 08/28/2018] [Indexed: 11/15/2022] Open
Abstract
Radiation therapy plays a significant role in management of benign and malignant diseases of the central nervous system. Patients may be at risk of acute and late toxicity from radiation therapy due to dose deposition in critical normal structures. In contrast to conventional photon delivery techniques, proton therapy is characterized by Bragg peak dose deposition which results in decreased exit dose beyond the target and greater sparing of normal structure which may reduce the rate of late toxicities from treatment. Dosimetric studies have demonstrated reduced dose to normal structures using proton therapy as compared to photon therapy. In addition, clinical studies are being reported demonstrating safety, feasibility, and low rates of acute toxicity. Technical challenges in proton therapy remain, including full understanding of depth of proton penetration and the biological activity in the distal Bragg peak. In addition, longer clinical follow-up is required to demonstrate reduction in late toxicities as compared to conventional photon-based radiation techniques. In this review, we summarize the current clinical literature and areas of active investigation in proton therapy for adult central nervous system malignancies.
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Affiliation(s)
- Jennifer Vogel
- Department of Rad-iation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ruben Carmona
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Christopher G Ainsley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
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20
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Cao H, Xiao Z, Zhang Y, Kwong T, Danish SF, Weiner J, Wang X, Yue N, Dai Z, Kuang Y, Bai Y, Nie K. Dosimetric comparisons of different hypofractionated stereotactic radiotherapy techniques in treating intracranial tumors > 3 cm in longest diameter. J Neurosurg 2020; 132:1024-1032. [PMID: 30901747 DOI: 10.3171/2018.12.jns181578] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to compare the dosimetric quality of hypofractionated stereotactic radiosurgery in treating sizeable brain tumors across the following treatment platforms: GammaKnife (GK) Icon, CyberKnife (CK) G4, volumetric modulated arc therapy (VMAT) on the Varian TrueBeam STx, double scattering proton therapy (DSPT) on the Mevion S250, and intensity modulated proton therapy (IMPT) on the Varian ProBeam. METHODS In this retrospective study, stereotactic radiotherapy treatment plans were generated for 10 patients with sizeable brain tumors (> 3 cm in longest diameter) who had been treated with VMAT. Six treatment plans, 20-30 Gy in 5 fractions, were generated for each patient using the same constraints for each of the following radiosurgical methods: 1) GK, 2) CK, 3) coplanar arc VMAT (VMAT-C), 4) noncoplanar arc VMAT (VMAT-NC), 5) DSPT, and 6) IMPT. The coverage; conformity index; gradient index (GI); homogeneity index; mean and maximum point dose of organs at risk; total dose volume (V) in Gy to the normal brain for 2 Gy (V2), 5 Gy (V5), and 12 Gy (V12); and integral dose were compared across all platforms. RESULTS Among the 6 techniques, GK consistently produced a sharper dose falloff despite a greater central target dose. GK gave the lowest GI, with a mean of 2.7 ± 0.1, followed by CK (2.9 ± 0.1), VMAT-NC (3.1 ± 0.3), and VMAT-C (3.5 ± 0.3). The highest mean GIs for the proton beam treatments were 3.8 ± 0.4 for DSPT and 3.9 ± 0.4 for IMPT. The GK consistently targeted the lowest normal brain volume, delivering 5 to 12 Gy when treating relatively smaller- to intermediate-sized lesions (less than 15-20 cm3). Yet, the differences across the 6 modalities relative to GK decreased with the increase of target volume. In particular, the proton treatments delivered the lowest V5 to the normal brain when the target size was over 15-20 cm3 and also produced the lowest integral dose to the normal brain regardless of the target size. CONCLUSIONS This study provides an insightful understanding of dosimetric quality from both photon and proton treatment across the most advanced stereotactic radiotherapy platforms.
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Affiliation(s)
- Hongbin Cao
- 1Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyan Xiao
- 2Proton Therapy Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yin Zhang
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Tiffany Kwong
- 4Department of Radiological Science, University of California Irvine, Irvine, California
| | - Shabbar F Danish
- 5Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joseph Weiner
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Xiao Wang
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ning Yue
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Zhitao Dai
- 6Department of Radiation Oncology, Shanghai Hospital, The Second Military Medical University, Shanghai, China; and
| | - Yu Kuang
- 7Department of Medical Physics, University of Nevada, Las Vegas, Nevada
| | - Yongrui Bai
- 1Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ke Nie
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Shimanskiy VN, Karnaukhov VV, Galkin MV, Tanyashin SV, Golanov AV, Poshataev VK, Shevchenko KV. [Treatment of petroclival meningiomas: current state of the problem]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 83:78-89. [PMID: 32031171 DOI: 10.17116/neiro20198306178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Petroclival meningiomas (PCMs) are benign, slowly growing tumors. Surgery still remains the main treatment option for them. The desire for total resection of large extended PCMs often leads to the development or worsening of persistent neurological deficits. This paper presents a review of the world literature devoted to petroclival meningiomas. We discuss the issues of PCM classification, biology, diagnosis, and selection of the optimal algorithm for their treatment.
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Affiliation(s)
| | | | - M V Galkin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
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22
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The Natural Growth Rate of Skull Base Meningiomas Compared With Non-Skull Base Meningiomas. J Craniofac Surg 2019; 30:1231-1233. [DOI: 10.1097/scs.0000000000005468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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The Role of Particle Therapy for the Treatment of Skull Base Tumors and Tumors of the Central Nervous System (CNS). Top Magn Reson Imaging 2019; 28:49-61. [PMID: 31022048 DOI: 10.1097/rmr.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiation therapy (RT) is a mainstay in the interdisciplinary treatment of brain tumors of the skull base and brain. Technical innovations during the past 2 decades have allowed for increasingly precise treatment with better sparing of adjacent healthy tissues to prevent treatment-related side effects that influence patients' quality of life. Particle therapy with protons and charged ions offer favorable kinetics with sharp dose deposition in a well-defined depth (Bragg-Peak) and a steep radiation fall-off beyond that maximum. This review highlights the role of particle therapy in the management of primary brain tumors and tumors of the skull base.
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Ichimura S, Kawase T. Effects of Surgery and Radiotherapy on Recurrent Skull Base Meningiomas: Clinical and Biological Analyses. J Neurol Surg B Skull Base 2018; 80:474-479. [PMID: 31534888 DOI: 10.1055/s-0038-1676373] [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: 06/22/2018] [Accepted: 10/13/2018] [Indexed: 01/12/2023] Open
Abstract
We reviewed the medical records of 392 patients who underwent initial surgery for skull base meningiomas between 1983 and 2008. Among them, 32 (8.2%) showed tumor recurrence. Risk factors for recurrence were analyzed clinically and biologically. Recurrent cases were treated with radiotherapy, surgery, or both. In reoperation cases, pathological and biological changes were analyzed and compared between groups with or without radiotherapy. The recurrence rate was statistically high in cases of partial tumor removal and in patients with tumor in the cavernous sinus, tumors with histological WHO (World Health Organization) grade ≥ II or MIB-1 index > 3. The local control rate of postoperative radiotherapy for recurrent cases was 66.7%. Malignant transformation and MIB-1 index elevation was observed more frequently in patients who underwent reoperation after radiotherapy than in the reoperation-only group. Risk factors for recurrence of skull base meningiomas are as follows: (1) partial tumor removal, (2) tumor in the cavernous sinus, (3) histological WHO grade ≥ II, or (4) MIB-1 index > 3. Postoperative radiotherapy might be effective for tumor recurrence. However, the indications for radiotherapy should be carefully considered because postsurgical radiotherapy may increase biological activity, inducing malignant transformation.
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Affiliation(s)
- Shinya Ichimura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.,Department of Neurosurgery, Shizuoka City Shimizu Hospital, Shizuoka, Japan
| | - Takeshi Kawase
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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Proton therapy for treatment of intracranial benign tumors in adults: A systematic review. Cancer Treat Rev 2018; 72:56-64. [PMID: 30530009 DOI: 10.1016/j.ctrv.2018.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 11/28/2018] [Accepted: 11/30/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The depth-dose distribution of a proton beam, materialized by the Bragg peak makes it an attractive radiation modality as it reduces exposure of healthy tissues to radiations, compared with photon therapy Prominent indications, based on a long-standing experience are: intraocular melanomas, low-grade skull-base and spinal canal malignancies. However, many others potential indications are under investigations such as the benign morbid conditions that are compatible with an extended life-expectancy: low grade meningiomas, paragangliomas, pituitary adenomas, neurinomas craniopharyngioma or recurrent pleomorphic adenomas. MATERIALS Given the radiation-induced risk of secondary cancer and the potential neurocognitive and functional alteration with photonic radiotherapy, we systematically analyzed the existing clinical literature about the use of proton therapy as an irradiation modality for cervical or intracranial benign tumors. The aim of this review was to report clinical outcomes of adult patients with benign intracranial or cervical tumors treated with proton therapy and to discuss about potential advantages of proton therapy over intensity modulated radiotherapy or radiosurgery. RESULTS Twenty-four studies were included. There was no randomized studies. Most studies dealt with low grade meningiomas (n = 9). Studies concerning neurinoma (n = 4), pituitary adenoma (n = 5), paraganglioma (n = 5), or craniopharyngioma (n = 1) were fewer. Whatever the indication, long term local control was systematically higher than 90% and equivalent to series with conventional radiotherapy. CONCLUSION Proton-therapy for treatment of adult benign intracranial and cervical tumors is safe. Randomized or prospective cohorts with long term cognitive evaluations are needed to assess the real place of proton-therapy in the treatment of adults benign head and neck tumors.
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Abstract
The physical characteristics of proton therapy result in steeper dose gradients and superior dose conformality compared to photon therapy. These properties render proton therapy ideal for skull base tumors requiring dose escalation for optimal tumor control, and may also be beneficial for brain tumors as a means of mitigating radiation-related adverse effects. This review summarizes the literature regarding the role of proton therapy compared to photon therapy in the treatment of adult brain and skull base tumors.
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Affiliation(s)
- Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Wang C, Kaprealian TB, Suh JH, Kubicky CD, Ciporen JN, Chen Y, Jaboin JJ. Overall survival benefit associated with adjuvant radiotherapy in WHO grade II meningioma. Neuro Oncol 2018; 19:1263-1270. [PMID: 28371851 DOI: 10.1093/neuonc/nox007] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Adjuvant radiotherapy (RT) after surgical resection of World Health Organization (WHO) grade II meningioma, also known as atypical meningioma (AM), is a topic of controversy. The purpose of this study is to compare overall survival (OS) with or without adjuvant RT after subtotal resection (STR) or gross total resection (GTR) in AM patients diagnosed according to the 2007 WHO classification. Methods The National Cancer Database was used to identify 2515 patients who were diagnosed with AM between 2009 and 2012 and underwent STR or GTR with or without adjuvant RT. Propensity score matching was first applied to balance covariates including age, year of diagnosis, sex, race, histology, and tumor size in STR or GTR cohorts stratified by adjuvant RT status. Multivariate regression according to the Cox proportional hazards model and Kaplan-Meier survival plots with log-rank test were then used to evaluate OS difference associated with adjuvant RT. Results GTR is associated with improved OS compared with STR. In the subgroup analysis, adjuvant RT in patients who underwent STR demonstrated significant association with improved OS compared with no adjuvant RT (adjusted hazard ratio [AHR] 0.590, P = .045); however, adjuvant RT is not associated with improved OS in patients who underwent GTR (AHR 1.093, P = .737). Conclusions Despite the lack of consensus on whether adjuvant RT reduces recurrence after surgical resection of AM, our study observed significantly improved OS with adjuvant RT compared with no adjuvant RT after STR.
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Affiliation(s)
- Chenyang Wang
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
| | - Tania B Kaprealian
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
| | - John H Suh
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
| | - Charlotte D Kubicky
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
| | - Jeremy N Ciporen
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
| | - Yiyi Chen
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
| | - Jerry J Jaboin
- UCLA Department of Radiation Oncology, Los Angeles, California; Cleveland Clinic Department of Radiation Oncology, Cleveland, Ohio; Oregon Health & Science University Department of Radiation Medicine, Portland, Oregon; Oregon Health & Science University Department of Neurosurgery, Center for Health & Healing, Portland, Oregon; Oregon Health & Science University Department of Public Health & Preventive Medicine, Portland, Oregon
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El Shafie RA, Czech M, Kessel KA, Habermehl D, Weber D, Rieken S, Bougatf N, Jäkel O, Debus J, Combs SE. Clinical outcome after particle therapy for meningiomas of the skull base: toxicity and local control in patients treated with active rasterscanning. Radiat Oncol 2018; 13:54. [PMID: 29587795 PMCID: PMC5870393 DOI: 10.1186/s13014-018-1002-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 03/16/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Meningiomas of the skull base account for 25-30% of all meningiomas. Due to the complex structure of the cranial base and its close proximity to critical structures, surgery is often associated with substantial morbidity. Treatment options include observation, aggressive surgical intervention, stereotactic or conventional radiotherapy. In this analysis we evaluate the outcome of 110 patients with meningiomas of the skull base treated with particle therapy. It was performed within the framework of the "clinical research group heavy ion therapy" and supported by the German Research Council (DFG, KFO 214). METHODS Between May 2010 and November 2014, 110 Patients with skull base meningioma were treated with particle radiotherapy at the Heidelberg Ion Therapy Center (HIT). Primary localizations included the sphenoid wing (n = 42), petroclival region (n = 23), cavernous sinus (n = 4), sella (n = 10) and olfactory nerve (n = 4). Sixty meningiomas were benign (WHO °I); whereas 8 were high-risk (WHO °II (n = 7) and °III (n = 1)). In 42 cases histology was not examined, since no surgery was performed. Proton (n = 104) or carbon ion (n = 6) radiotherapy was applied at Heidelberg Ion Therapy Center (HIT) using raster-scanning technique for active beam delivery. Fifty one patients (46.4%) received radiotherapy due to tumor progression, 17 (15.5%) after surgical resection and 42 (38.2%) as primary treatment. RESULTS Median follow-up in this analysis was 46,8 months (95% CI 39,9-53,7; Q1-Q3 34,3-61,7). Particle radiotherapy could be performed safely without toxicity-related interruptions. No grade IV or V toxicities according to CTCAE v4.0 were observed. Particle RT offered excellent overall local control rates with 100% progression-free survival (PFS) after 36 months and 96.6% after 60 months. Median PFS was not reached due to the small number of events. Histology significantly impacted PFS with superior PFS after 5 years for low-risk tumors (96.6% vs. 75.0%, p = 0,02). Overall survival was 96.2% after 60 months and 92.0% after 72 months from therapy. Of six documented deaths, five were definitely not and the sixth probably not meningioma-related. CONCLUSION Particle radiotherapy is an excellent treatment option for patients with meningiomas of the skull base and can lead to long-term tumor control with minimal side effects. Other prospective studies with longer follow-up will be necessary to further confirm the role of particle radiotherapy in skull base meningioma.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Maja Czech
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Helmholtz Zentrum München, Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Ingolstädter Landstraße 1, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Helmholtz Zentrum München, Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Ingolstädter Landstraße 1, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Dorothea Weber
- Institute for Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 470, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Nina Bougatf
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 470, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Oliver Jäkel
- Deutsches Krebsforschungszentrum (dkfz), Abteilung Medizinphysik, Im Neuenheimer Feld 270, 69120, Heidelberg, Germany.,Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 470, 69120, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion Therapy Center (HIT), Im Neuenheimer Feld 470, 69120, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Helmholtz Zentrum München, Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Ingolstädter Landstraße 1, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
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Pereira BJA, de Almeida AN, Paiva WS, Teixeira MJ, Marie SKN. Impact of radiotherapy in atypical meningioma recurrence: literature review. Neurosurg Rev 2018; 42:631-637. [PMID: 29552691 DOI: 10.1007/s10143-018-0959-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 01/29/2018] [Accepted: 02/20/2018] [Indexed: 12/14/2022]
Abstract
Evaluate whether radiotherapy (RT) after the neurosurgical treatment of atypical meningiomas (AM) has an impact on the reduction rate of recurrence. A Medline search through October 2017 using "atypical meningioma" returned 1277 papers for initial review. Inclusion criteria were as follows. We analyzed the database and included articles in which the anatomic pathological classification of atypical meningiomas was in accordance with WHO 2007 or WHO 2016 criteria, patients > 18 years of age, and there was postoperative external beam radiation to the tumor bed. Exclusion criteria were WHO grade I or III meningioma, patients who underwent whole-brain radiation, RT used as salvage therapy for recurrence, palliative dose of RT (< 45 Gy), recurrent AMs, and multiple AMs. Papers reporting outcomes in which atypical and anaplastic meningiomas were analyzed together were rejected, as were papers with small samples that may compromise evaluation. After filtering our initial selection, only 17 papers were selected. After reviewing the seventeen articles including a total of 1761 patients (972 female and 799 male; 1.21 female/1.0 male), the difference in proportion of tumor recurrence between patients with and without radiotherapy after neurosurgical procedure was 1.0448, 95% CI [0.8318 to 1.3125], p value = 0.7062. On the basis of this review, there is no evidence to suggest that RT decreases the rate of recurrence in patients with atypical meningiomas.
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Affiliation(s)
- Benedito Jamilson Araújo Pereira
- Departamento de Neurologia da Faculdade de Medicina, da Universidade de São Paulo-SP, Rua Martiniano de Carvalho, 669, Edifício Paulista Paradise Life, Apto 1105, São Paulo, Brazil.
| | - Antônio Nogueira de Almeida
- Divisão de Neurocirurgia Funcional IPQ. Hospital das Clínicas, da Universidade de São Paulo-SP, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Departamento de Neurologia da Faculdade de Medicina, da Universidade de São Paulo-SP, Rua Martiniano de Carvalho, 669, Edifício Paulista Paradise Life, Apto 1105, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Departamento de Neurologia da Faculdade de Medicina, da Universidade de São Paulo-SP, Rua Martiniano de Carvalho, 669, Edifício Paulista Paradise Life, Apto 1105, São Paulo, Brazil
| | - Suely Kazue Nagahashi Marie
- Departamento de Neurologia da Faculdade de Medicina, da Universidade de São Paulo-SP, Rua Martiniano de Carvalho, 669, Edifício Paulista Paradise Life, Apto 1105, São Paulo, Brazil
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Tessonnier T, Mairani A, Chen W, Sala P, Cerutti F, Ferrari A, Haberer T, Debus J, Parodi K. Proton and helium ion radiotherapy for meningioma tumors: a Monte Carlo-based treatment planning comparison. Radiat Oncol 2018; 13:2. [PMID: 29316969 PMCID: PMC5759862 DOI: 10.1186/s13014-017-0944-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 12/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to their favorable physical and biological properties, helium ion beams are increasingly considered a promising alternative to proton beams for radiation therapy. Hence, this work aims at comparing in-silico the treatment of brain and ocular meningiomas with protons and helium ions, using for the first time a dedicated Monte Carlo (MC) based treatment planning engine (MCTP) thoroughly validated both in terms of physical and biological models. METHODS Starting from clinical treatment plans of four patients undergoing proton therapy with a fixed relative biological effectiveness (RBE) of 1.1 and a fraction dose of 1.8 Gy(RBE), new treatment plans were optimized with MCTP for both protons (with variable and fixed RBE) and helium ions (with variable RBE) under the same constraints derived from the initial clinical plans. The resulting dose distributions were dosimetrically compared in terms of dose volume histograms (DVH) parameters for the planning target volume (PTV) and the organs at risk (OARs), as well as dose difference maps. RESULTS In most of the cases helium ion plans provided a similar PTV coverage as protons with a consistent trend of superior OAR sparing. The latter finding was attributed to the ability of helium ions to offer sharper distal and lateral dose fall-offs, as well as a more favorable differential RBE variation in target and normal tissue. CONCLUSIONS Although more studies are needed to investigate the clinical potential of helium ions for different tumour entities, the results of this work based on an experimentally validated MC engine support the promise of this modality with state-of-the-art pencil beam scanning delivery, especially in case of tumours growing in close proximity of multiple OARs such as meningiomas.
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Affiliation(s)
- Thomas Tessonnier
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Andrea Mairani
- Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
- Centro Nazionale di Adroterapia Oncologica, Pavia, Italy
| | - Wenjing Chen
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Paola Sala
- Istituto Nazionale di Fisica Nucleare, Sezione di Milano, Milan, Italy
- European Organization for Nuclear Research, CERN, Geneva, Switzerland
| | - Francesco Cerutti
- European Organization for Nuclear Research, CERN, Geneva, Switzerland
| | - Alfredo Ferrari
- European Organization for Nuclear Research, CERN, Geneva, Switzerland
| | | | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
| | - Katia Parodi
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Munich, Germany
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Hypofractionated high-energy proton-beam irradiation is an alternative treatment for WHO grade I meningiomas. Acta Neurochir (Wien) 2017; 159:2391-2400. [PMID: 29064038 PMCID: PMC5686253 DOI: 10.1007/s00701-017-3352-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/02/2017] [Indexed: 11/25/2022]
Abstract
Background Radiation treatment is commonly employed in the treatment of meningiomas. The aim of this study was to evaluate the effectiveness and safety of hypofractionated high-energy proton therapy as adjuvant or primary treatment for WHO grade I meningiomas. Method A total of 170 patients who received irradiation with protons for grade I meningiomas between 1994 and 2007 were included in the study. The majority of the tumours were located at the skull base (n = 155). Eighty-four patients were treated post subtotal resection, 42 at tumour relapse and 44 with upfront radiotherapy after diagnosis based on the typical radiological image. Irradiation was given in a hypofractionated fashion (3–8 fractions, usually 5 or 6 Gy) with a mean dose of 21.9 Gy (range, 14–46 Gy). All patients were planned for follow-up with clinical controls and magnetic resonance imaging scans at 6 months and 1, 2, 3, 5, 7 and 10 years after treatment. The median follow-up time was 84 months. Age, gender, tumour location, Simpson resection grade and target volume were assessed as possible prognostic factors for post-irradiation tumour progression and radiation related complications. Results The actuarial 5- and 10-year progression-free survival rates were 93% and 85% respectively. Overall mortality rate was 13.5%, while disease-specific mortality was 1.7% (3/170 patients). Older patients and patients with tumours located in the middle cranial fossa had a lower risk for tumour progression. Radiation-related complications were seen in 16 patients (9.4%), with pituitary insufficiency being the most common. Tumour location in the anterior cranial fossa was the only factor that significantly increased the risk of complications. Conclusions Hypofractionated proton-beam radiation therapy may be used particularly in the treatment of larger World Health Organisation grade I meningiomas not amenable to total surgical resection. Treatment is associated with high rates of long-term tumour growth control and acceptable risk for complications.
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Adeberg S, Harrabi SB, Verma V, Bernhardt D, Grau N, Debus J, Rieken S. Treatment of meningioma and glioma with protons and carbon ions. Radiat Oncol 2017; 12:193. [PMID: 29195506 PMCID: PMC5710063 DOI: 10.1186/s13014-017-0924-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
The rapid rise of particle therapy across the world necessitates evidence to justify its ever-increasing utilization. This narrative review summarizes the current status of these technologies on treatment of both meningiomas and gliomas, the most common benign and malignant primary brain tumors, respectively. Proton beam therapy (PBT) for meningiomas displays high rates of long-term local control, low rates of symptomatic deterioration, along with the potential for safe dose-escalation in select (but not necessarily routine) cases. PBT is also associated with low adverse events and maintenance of functional outcomes, which have implications for quality of life and cost-effectiveness measures going forward. Data on carbon ion radiation therapy (CIRT) are limited; existing series describe virtually no high-grade toxicities and high local control. Regarding the few available data on low-grade gliomas, PBT provides opportunities to dose-escalate while affording no increase of severe toxicities, along with maintaining appropriate quality of life. Although dose-escalation for low-grade disease has been less frequently performed than for glioblastoma, PBT and CIRT continue to be utilized for the latter, and also have potential for safer re-irradiation of high-grade gliomas. For both neoplasms, the impact of superior dosimetric profiles with endpoints such as neurocognitive decline and neurologic funcionality, are also discussed to the extent of requiring more data to support the utility of particle therapy. Caveats to these data are also described, such as the largely retrospective nature of the available studies, patient selection, and heterogeneity in patient population as well as treatment (including mixed photon/particle treatment). Nevertheless, multiple prospective trials (which may partially attenuate those concerns) are also discussed. In light of the low quantity and quality of available data, major questions remain regarding economic concerns as well.
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Affiliation(s)
- Sebastian Adeberg
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Heidelberg Ion-Beam Therapy Center, Im Neuenheimer Feld 450, 69120, Heidelberg, Germany. .,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany.
| | - Semi B Harrabi
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, 505 S 45th Street, Omaha, NE, 68106, USA
| | - Denise Bernhardt
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Nicole Grau
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
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Murray FR, Snider JW, Bolsi A, Lomax AJ, Walser M, Kliebsch U, Schneider RA, Weber DC. Long-Term Clinical Outcomes of Pencil Beam Scanning Proton Therapy for Benign and Non-benign Intracranial Meningiomas. Int J Radiat Oncol Biol Phys 2017; 99:1190-1198. [PMID: 28939227 DOI: 10.1016/j.ijrobp.2017.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/24/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To assess and report long-term clinical outcomes regarding local control, overall survival, and toxicity-free survival after pencil beam scanning proton therapy for intracranial meningiomas at a single institution. PATIENTS AND METHODS Ninety-six patients (male/female, 29/67; median age 52.8 years) with intracranial meningiomas (World Health Organization [WHO] grade 1, n=61 [63.5%]; WHO grade 2, n=33 [34.4%]; WHO grade 3, n=2 [2.1%]) were treated with pencil beam scanning proton therapy (n=53 [55.2%] at diagnosis, n=17 [17.7%] at recurrence, and n=26 [27.1%] for tumor progression). Median gross tumor volume before PBSPT was 21.4 cm3 (range, 0.0-546.5 cm3), with a median planning target volume of 123.4 cm3 (range, 4.6-1142.0 cm3). Median duration of follow-up was 56.9 months (range, 12.1-207.2 months). Late toxicity was graded according to the Common Terminology Criteria for Adverse Events, version 4.0. RESULTS Thirteen failures (14%) (male/female, 6/7) were observed, of which the majority (n=9, 69%) were of non-benign histology. The 5-year actuarial local control and overall survival were 86.4% and 88.2%, respectively. Five-year grade ≥3 toxicity-free survival was 89.1%. On univariate analysis, local control was worse for patients with higher WHO grade (P≤.001), those treated after at least 1 recurrence (P=.006), those with non-skull base tumor location (P=.014), and males (P=.032). Significant prognosticators for 5-year overall survival were local control (P≤.001), age (P=.002), and timing of proton therapy (initial vs recurrence) (P=.002). CONCLUSIONS Pencil beam scanning proton therapy is an effective and safe treatment for patients with intracranial meningiomas, resulting in high local control rates with limited toxicity. Up-front radiation likely results in improved outcomes and should be considered, especially for patients with non-benign tumors and/or for those with incomplete resections.
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Affiliation(s)
- Fritz R Murray
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.
| | - James W Snider
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland; Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland
| | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Ulrike Kliebsch
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Ralf A Schneider
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland; University of Bern, Bern, Switzerland; University of Zürich, Zürich, Switzerland
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Abstract
OPINION STATEMENT Proton therapy is characterized by certain physical properties leading to a reduction in integral dose. As proton therapy becomes more widely available, the ongoing discussion on the real indications for proton therapy becomes more important. In the present article, data on proton therapy for tumors of the central nervous system (CNS) is summarized and discussed in view of modern photon treatments. Still today, no randomized controlled trials are available confirming any clinical benefit of protons in CNS tumors. For certain skull base lesions, such as chordomas and chondrosarcomas, dose escalation is possible with protons thus patients should be referred to a proton center if readily available. For vestibular schwannoma, at present, proton data are inferior to advanced photons. For glioma patients, early data is present for low-grade gliomas, presenting comparable results to photons; dose escalation studies for high-grade gliomas have led to significant side effects, thus strategies of dose-escalation need to rethought. For skull base meningiomas, data from stereotactic series and IMRT present excellent local control with minimal side effects, thus any improvement with protons might only be marginal. The largest benefit is considered in pediatric CNS tumors, due to the intricate radiation sensitivity of children's normal tissue, as well as the potential of long-term survivorship. Long-term data is still lacking, and even recent analyses do not all lead to a clear reduction in side effects with improvement of outcome; furthermore, clinical data seem to be comparable. However, based on the preclinical evidence, proton therapy should be evaluated in every pediatric patient. Protons most likely have a benefit in terms of reduction of long-term side effects, such as neurocognitive sequelae or secondary malignancies; moreover, dose escalation can be performed in radio-resistant histologies. Clinical data with long-term follow-up is still warranted to prove any superiority to advanced photons in CNS tumors. If available, protons should be evaluated for chordoma or chondrosarcoma of the skull base and pediatric tumors. However, many factors are important for excellent oncology care, and no time delay or inferior oncological care should be accepted for the sake of protons only.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.
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Vernimmen F. Intracranial Stereotactic Radiation Therapy With Charged Particle Beams: An Opportunity to Regain the Momentum. Int J Radiat Oncol Biol Phys 2016; 95:52-55. [DOI: 10.1016/j.ijrobp.2015.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/03/2015] [Accepted: 10/06/2015] [Indexed: 11/16/2022]
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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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Long-term evaluation of the effect of hypofractionated high-energy proton treatment of benign meningiomas by means of (11)C-L-methionine positron emission tomography. Eur J Nucl Med Mol Imaging 2016; 43:1432-43. [PMID: 26819102 DOI: 10.1007/s00259-016-3310-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To determine if (11)C-L-methionine PET is a useful tool in the evaluation of the long-term effect of proton beam treatment in patients with meningioma remnant. METHODS Included in the study were 19 patients (4 men, 15 women) with intracranial meningioma remnants who received hypofractionated high-energy proton beam treatment. Patients were examined with (11)C-L-methionine PET and MRI prior to treatment and after 6 months, and 1, 2, 3, 5, 7 and 10 years. Temporal changes in methionine uptake ratio, meningioma volume, meningioma regrowth and clinical symptoms throughout the follow-up period were evaluated. RESULTS In 17 patients the tumour volume was unchanged throughout the follow-up. The methionine uptake ratio on PET decreased over the years in most patients. In two patients the tumour remnant showed progression on MRI. In these patients, prior to the volume increase on MRI, the methionine uptake ratio increased. One patient experienced transient clinical symptoms and showed radiological evidence of a radiation-induced reaction close to the irradiated field. CONCLUSION Proton beam treatment is a safe and effective treatment for achieving long-term growth arrest in meningioma remnants. Follow-up with (11)C-L-methionine PET may be a valuable adjunct to, but not a replacement for, standard radiological follow-up.
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Mansouri A, Guha D, Klironomos G, Larjani S, Zadeh G, Kondziolka D. Stereotactic radiosurgery for intracranial meningiomas: current concepts and future perspectives. Neurosurgery 2015; 76:362-71. [PMID: 25599213 DOI: 10.1227/neu.0000000000000633] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Meningiomas are among the most common adult brain tumors. Although the optimal management of meningiomas would provide complete elimination of the lesion, this cannot always be accomplished safely through resection. Therefore, other therapeutic modalities, such as stereotactic radiosurgery (as primary or adjunctive therapy), have emerged. In the current review, we have provided an overview of the historical outcomes of various radiosurgical modalities applied in the management of meningiomas. Furthermore, we provide a discussion on key factors (eg World Health Organization grade, lesion size, and lesion location) that affect tumor control and adverse event rates. We discuss recent changes in our understanding of meningiomas, based on molecular and genetic markers, and how these will change our perspective on the management of meningiomas. We conclude by outlining the areas in which knowledge gaps persist and provide suggestions as to how these can be addressed.
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Affiliation(s)
- Alireza Mansouri
- *Division of Neurosurgery, University of Toronto, Toronto, Canada; ‡Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto Canada; §Departments of Neurosurgery and Radiation Oncology, NYU Langone Medical Center, New York University
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Hypofractionated stereotactic radiation therapy in skull base meningiomas. J Neurooncol 2015; 124:283-9. [PMID: 26040487 DOI: 10.1007/s11060-015-1838-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/30/2015] [Indexed: 12/12/2022]
Abstract
To investigate the role of hypo-fractionated stereotactic radiation treatment (HSRT) in the management of skull base meningioma. Twenty-six patients were included in the study and treated with a dose of 30 Gy in 5 fractions with volumetric modulated arc therapy (RapidArc). Eighteen patients were symptomatic before treatment. Endpoints were local toxicity and relief from symptoms. Tumors were located in anterior skull base in 4/27 cases, in middle skull base in 12/27 and in posterior skull base in 11/27. HSRT was performed as first treatment in 17 (65 %) patients, in 9 (35 %) patients it followed a previous partial resection. Median follow up was 24.5 months (range 5-57 months). clinical remission of symptoms, complete or partial, was obtained in the vast majority of patients after treatment. Out of the 18 symptomatic patients, partial remission occurred in 9 (50 %) patients and complete remission in 9 (50 %). All asymptomatic patients retained their status after treatment. No severe neurologic toxicity grade III-IV was recorded. No increase of meningioma in the same site of treatment occurred; 16 (62 %) patients had stable disease and 9 (38 %) patients had tumor reduction. The mean tumor volume after treatment was 10.8 ± 17.8 cm(3) compared with 13.0 ± 19.1 cm(3) before treatment (p = 0.02). The mean actuarial OS was 54.4 ± 2.8 months. The 1- and 2-years OS was 92.9 ± 0.7 %. HSRT proved to be feasible for these patients not eligible to full surgery or to ablative radiation therapy. Local control and durability of results suggest for a routine application of this approach in properly selected cases.
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Rogers L, Barani I, Chamberlain M, Kaley T, McDermott M, Raizer J, Schiff D, Weber DC, Wen PY, Vogelbaum MA. Meningiomas: knowledge base, treatment outcomes, and uncertainties. A RANO review. J Neurosurg 2015; 122:4-23. [PMID: 25343186 PMCID: PMC5062955 DOI: 10.3171/2014.7.jns131644] [Citation(s) in RCA: 396] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Evolving interest in meningioma, the most common primary brain tumor, has refined contemporary management of these tumors. Problematic, however, is the paucity of prospective clinical trials that provide an evidence-based algorithm for managing meningioma. This review summarizes the published literature regarding the treatment of newly diagnosed and recurrent meningioma, with an emphasis on outcomes stratified by WHO tumor grade. Specifically, this review focuses on patient outcomes following treatment (either adjuvant or at recurrence) with surgery or radiation therapy inclusive of radiosurgery and fractionated radiation therapy. Phase II trials for patients with meningioma have recently completed accrual within the Radiation Therapy Oncology Group and the European Organisation for Research and Treatment of Cancer consortia, and Phase III studies are being developed. However, at present, there are no completed prospective, randomized trials assessing the role of either surgery or radiation therapy. Successful completion of future studies will require a multidisciplinary effort, dissemination of the current knowledge base, improved implementation of WHO grading criteria, standardization of response criteria and other outcome end points, and concerted efforts to address weaknesses in present treatment paradigms, particularly for patients with progressive or recurrent low-grade meningioma or with high-grade meningioma. In parallel efforts, Response Assessment in Neuro-Oncology (RANO) subcommittees are developing a paper on systemic therapies for meningioma and a separate article proposing standardized end point and response criteria for meningioma.
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Affiliation(s)
- Leland Rogers
- GammaWest Cancer Services, Radiation Oncology, Salt Lake City, UT
| | - Igor Barani
- University of California San Francisco, Department of Radiation Oncology, San Francisco, CA
| | - Marc Chamberlain
- University of Washington, Department of Neurology, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Thomas Kaley
- Memorial Sloan-Kettering Cancer Center, Division of Neuro-Oncology, New York, NY
| | - Michael McDermott
- University of California, San Francisco, Department of Neurosurgery, San Francisco, CA
| | - Jeffrey Raizer
- Northwestern University, Department of Neurology, Chicago, IL
| | - David Schiff
- Neuro-Oncology Center, University of Virginia. Charlottesville, VA
| | - Damien C. Weber
- Geneva University Hospital, Radiation Oncology, Geneva, Switzerland
| | - Patrick Y. Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women’s Center, Boston, MA
| | - Michael A. Vogelbaum
- Cleveland Clinic, Brain Tumor and NeuroOncology Center and Department of Neurosurgery, Cleveland, OH
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Krengli M, Apicella G, Deantonio L, Paolini M, Masini L. Stereotactic radiation therapy for skull base recurrences: Is a salvage approach still possible? Rep Pract Oncol Radiother 2014; 20:430-9. [PMID: 26696783 DOI: 10.1016/j.rpor.2014.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/30/2014] [Accepted: 10/10/2014] [Indexed: 12/22/2022] Open
Abstract
AIM A literature review was performed to analyse the role of stereotactic radiotherapy given in a single shot or in a fractionated fashion for recurrent skull base tumours in order to ascertain if it can be a real salvage approach. BACKGROUND The management of recurrent skull base tumours can have a curative or palliative intent and mainly includes surgery and RT. MATERIALS AND METHODS One-thousand-ninety-one articles were found in the search databases and the most relevant of them were analysed and briefly described. RESULTS Data on recurrences of meningioma, pituitary adenoma, craniopharyngioma, chordoma and chondrosarcoma, vestibular schwannoma, glomus jugulare tumours, olfactory neuroblastoma and recurrences from head and neck tumours invading the base of skull are reported highlighting the most relevant results in terms of local control, survival, side effects and complications. CONCLUSIONS In conclusion, it emerges that SRS and FSRT are effective and safe radiation modalities of realize real salvage treatment for recurrent skull base tumours.
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Affiliation(s)
- Marco Krengli
- Chair of Radiotherapy, University Hospital "Maggiore della Carità", Novara, Italy ; Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy
| | - Giuseppina Apicella
- Chair of Radiotherapy, University Hospital "Maggiore della Carità", Novara, Italy
| | - Letizia Deantonio
- Chair of Radiotherapy, University Hospital "Maggiore della Carità", Novara, Italy ; Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy
| | - Marina Paolini
- Chair of Radiotherapy, University Hospital "Maggiore della Carità", Novara, Italy
| | - Laura Masini
- Chair of Radiotherapy, University Hospital "Maggiore della Carità", Novara, Italy
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Quantitative analysis of tumor volume reduction after three-dimensional conformal radiation therapy for intracranial meningiomas. J Neurooncol 2014; 121:195-9. [DOI: 10.1007/s11060-014-1625-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
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Marta GN, Correa SFM, Teixeira MJ. Meningioma: review of the literature with emphasis on the approach to radiotherapy. Expert Rev Anticancer Ther 2014; 11:1749-58. [DOI: 10.1586/era.11.162] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Maclean J, Fersht N, Short S. Controversies in radiotherapy for meningioma. Clin Oncol (R Coll Radiol) 2013; 26:51-64. [PMID: 24207113 DOI: 10.1016/j.clon.2013.10.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 08/21/2013] [Accepted: 10/02/2013] [Indexed: 10/26/2022]
Abstract
Meningiomas are the most common primary intracranial tumour. Although external beam radiotherapy and radiosurgery are well-established treatments, affording local control rates of 85-95% at 10 years, the evidence base is mainly limited to single institution case series. This has resulted in inconsistent practices. It is generally agreed that radiotherapy is an established primary therapy in patients requiring treatment for surgically inaccessible disease and postoperatively for grade 3 tumours. Controversy exists surrounding whether radiotherapy should be upfront or reserved for progression for incompletely excised and grade 2 tumours. External beam radiotherapy and radiosurgery have not been directly compared, but seem to offer comparable rates of control for benign disease. Target volume definition remains contentious, including the inclusion of hyperostotic bone, dural tail and surrounding brain, but pathological studies are shedding some light. Most agree that doses around 50-54 Gy are appropriate for benign meningiomas and ongoing European Organization for Research and Treatment of Cancer and Radiation Therapy Oncology Group studies are evaluating dose escalation for higher risk disease. Here we address the 'who, when and how' of radiotherapy for meningioma.
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Affiliation(s)
- J Maclean
- Department of Radiotherapy, University College London Hospitals NHS Trust, London, UK.
| | - N Fersht
- Department of Radiotherapy, University College London Hospitals NHS Trust, London, UK
| | - S Short
- Leeds Institute of Molecular Medicine, St James' University Hospital, Leeds, UK
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Diagnosis and management of optic nerve sheath meningiomas. J Clin Neurosci 2013; 20:1045-56. [DOI: 10.1016/j.jocn.2013.03.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 03/09/2013] [Indexed: 11/21/2022]
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Combs SE, Welzel T, Habermehl D, Rieken S, Dittmar JO, Kessel K, Jäkel O, Haberkorn U, Debus J. Prospective evaluation of early treatment outcome in patients with meningiomas treated with particle therapy based on target volume definition with MRI and 68Ga-DOTATOC-PET. Acta Oncol 2013; 52:514-20. [PMID: 23402336 DOI: 10.3109/0284186x.2013.762996] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To evaluate early treatment results and toxicity in patients with meningiomas treated with particle therapy. MATERIAL AND METHODS Seventy patients with meningiomas were treated with protons (n = 38) or carbon ion radiotherapy (n = 26). Median age was 49 years. Median age at treatment was 55 years, 24 were male (34%), and 46 were female (66%). Histology was benign meningioma in 26 patients (37%), atypical in 23 patients (33%) and anaplastic in four patients (6%). In 17 patients (24%) with skull base meningiomas diagnosis was based on the typical appearance of a meningioma. For benign meningiomas, total doses of 52.2-57.6 GyE were applied with protons. For high-grade lesions, the boost volume was 18 GyE carbon ions, with a median dose of 50 GyE applied as highly conformal radiation therapy. Nineteen patients were treated as re-irradiation. Treatment planning with MRI and 68-Ga-DOTATOC-PET was evaluated. RESULTS Very low rates of side effects developed, including headaches, nausea and dizziness. No severe treatment-related toxicity was observed. Local control for benign meningiomas was 100%. Five of 27 patients (19%) developed tumor recurrence during follow-up. Of these, four patients had been treated as re-irradiation for recurrent high-risk meningiomas. Actuarial local control after re-irradiation of high-risk meningiomas was therefore 67% at six and 12 months. In patients treated with primary radiotherapy, only one of 13 patients (8%) developed tumor recurrence 17 months after radiation therapy (photon and carbon ion boost). CONCLUSION Continuous prospective follow-up and development of novel study concepts are required to fully exploit the long-term clinical data after particle therapy for meningiomas. To date, it may be concluded that when proton therapy is available, meningioma patients can be offered a treatment at least comparable to high-end photon therapy.
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Affiliation(s)
- Stephanie E. Combs
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
| | - Thomas Welzel
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
| | - Daniel Habermehl
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
| | - Stefan Rieken
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
| | - Jan-Oliver Dittmar
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
| | - Kerstin Kessel
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
| | - Oliver Jäkel
- Heidelberg Ion Therapy Center (HIT),
Heidelberg, Germany
| | - Uwe Haberkorn
- University Hospital of Heidelberg, Department of Nuclear Medicine,
Heidelberg, Germany
| | - Jürgen Debus
- University Hospital of Heidelberg, Department of Radiation Oncology,
Heidelberg, Germany
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Combs SE, Ganswindt U, Foote RL, Kondziolka D, Tonn JC. State-of-the-art treatment alternatives for base of skull meningiomas: complementing and controversial indications for neurosurgery, stereotactic and robotic based radiosurgery or modern fractionated radiation techniques. Radiat Oncol 2012; 7:226. [PMID: 23273161 PMCID: PMC3551826 DOI: 10.1186/1748-717x-7-226] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 12/27/2012] [Indexed: 11/10/2022] Open
Abstract
For skull base meningiomas, several treatment paradigms are available: Observation with serial imaging, surgical resection, stereotactic radiosurgery, radiation therapy or some combination of both. The choice depends on several factors. In this review we evaluate different treatment options, the outcome of modern irradiation techniques as well as the clinical results available, and establish recommendations for the treatment of patients with skull-base meningiomas.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
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Amichetti M, Amelio D, Minniti G. Radiosurgery with photons or protons for benign and malignant tumours of the skull base: a review. Radiat Oncol 2012; 7:210. [PMID: 23241206 PMCID: PMC3552759 DOI: 10.1186/1748-717x-7-210] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 12/12/2012] [Indexed: 01/25/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is an important treatment option for intracranial lesions. Many studies have shown the effectiveness of photon-SRS for the treatment of skull base (SB) tumours; however, limited data are available for proton-SRS.Several photon-SRS techniques, including Gamma Knife, modified linear accelerators (Linac) and CyberKnife, have been developed and several studies have compared treatment plan characteristics between protons and photons.The principles of classical radiobiology are similar for protons and photons even though they differ in terms of physical properties and interaction with matter resulting in different dose distributions.Protons have special characteristics that allow normal tissues to be spared better than with the use of photons, although their potential clinical superiority remains to be demonstrated.A critical analysis of the fundamental radiobiological principles, dosimetric characteristics, clinical results, and toxicity of proton- and photon-SRS for SB tumours is provided and discussed with an attempt of defining the advantages and limits of each radiosurgical technique.
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Affiliation(s)
- Maurizio Amichetti
- ATreP, Provincial Agency for Proton Therapy, via Perini 181, Trento 38122, Italy.
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Slater JD, Loredo LN, Chung A, Bush DA, Patyal B, Johnson WD, Hsu FPK, Slater JM. Fractionated proton radiotherapy for benign cavernous sinus meningiomas. Int J Radiat Oncol Biol Phys 2012; 83:e633-7. [PMID: 22768992 DOI: 10.1016/j.ijrobp.2012.01.079] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 01/26/2012] [Accepted: 01/27/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy of fractionated proton radiotherapy for a population of patients with benign cavernous sinus meningiomas. METHODS AND MATERIALS Between 1991 and 2002, 72 patients were treated at Loma Linda University Medical Center with proton therapy for cavernous sinus meningiomas. Fifty-one patients had biopsy or subtotal resection; 47 had World Health Organization grade 1 pathology. Twenty-one patients had no histologic verification. Twenty-two patients received primary proton therapy; 30 had 1 previous surgery; 20 had more than 1 surgery. The mean gross tumor volume was 27.6 cm(3); mean clinical target volume was 52.9 cm(3). Median total doses for patients with and without histologic verification were 59 and 57 Gy, respectively. Mean and median follow-up periods were 74 months. RESULTS The overall 5-year actuarial control rate was 96%; the control rate was 99% in patients with grade 1 or absent histologic findings and 50% for those with atypical histology. All 21 patients who did not have histologic verification and 46 of 47 patients with histologic confirmation of grade 1 tumor demonstrated disease control at 5 years. Control rates for patients without previous surgery, 1 surgery, and 2 or more surgeries were 95%, 96%, and 95%, respectively. CONCLUSIONS Fractionated proton radiotherapy for grade 1 cavernous sinus meningiomas achieves excellent control rates with minimal toxicities, regardless of surgical intervention or use of histologic diagnosis. Disease control for large lesions can be achieved by primary fractionated proton therapy.
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Affiliation(s)
- Jerry D Slater
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA.
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