Fractionated Stereotactic Radiotherapy For the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization

Neurosurgery ◽  
2004 ◽  
Vol 55 (3) ◽  
pp. 519-531 ◽  
Author(s):  
Erol Veznedaroglu ◽  
David W. Andrews ◽  
Ronald P. Benitez ◽  
M. Beverly Downes ◽  
Maria Werner-Wasik ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Stereotactic Radiotherapy ◽  
Arteriovenous Malformations ◽  
Three Dimensional ◽  
Late Complications ◽  
Fractionated Stereotactic Radiotherapy ◽  
Medical Systems ◽  
Significant Treatment ◽  
Lost To Follow Up

Abstract OBJECTIVE: Despite the success of stereotactic radiosurgery, large inoperable arteriovenous malformations (AVMs) of 14 cm3 or more have remained largely refractory to stereotactic radiosurgery, with much lower obliteration rates. We review treatment of large AVMs either previously untreated or partially obliterated by embolization with fractionated stereotactic radiotherapy (FSR) regimens using a dedicated linear accelerator (LINAC). METHODS: Before treatment, all patients were discussed at a multidisciplinary radiosurgery board and found to be suitable for FSR. All patients were evaluated for pre-embolization. Those who had feeding pedicles amenable to glue embolization were treated. LINAC technique involved acquisition of a stereotactic angiogram in a relocatable frame that was also used for head localization during treatment. The FSR technique involved the use of six 7-Gy fractions delivered on alternate days over a 2-week period, and this was subsequently dropped to 5-Gy fractions after late complications in one of seven patients treated with 7-Gy fractions. Treatments were based exclusively on digitized biplanar stereotactic angiographic data. We used a Varian 600SR LINAC (Varian Medical Systems, Inc., Palo Alto, CA) and XKnife treatment planning software (Radionics, Inc., Burlington, MA). In most cases, one isocenter was used, and conformality was established by non-coplanar arc beam shaping and differential beam weighting. RESULTS: Thirty patients with large AVMs were treated between January 1995 and August 1998. Seven patients were treated with 42-Gy/7-Gy fractions, with one patient lost to follow-up and the remaining six with previous partial embolization. Twenty-three patients were treated with 30-Gy/5-Gy fractions, with two patients lost to follow-up and three who died as a result of unrelated causes. Of 18 evaluable patients, 8 had previous partial embolization. Mean AVM volumes at FSR treatment were 23.8 and 14.5 cm3, respectively, for the 42-Gy/7-Gy fraction and 30-Gy/5-Gy fraction groups. After embolization, 18 patients still had AVM niduses of 14 cm3 or more: 6 in the 7-Gy cohort and 12 in the 5-Gy cohort. For patients with at least 5-year follow-up, angiographically documented AVM obliteration rates were 83% for the 42-Gy/7-Gy fraction group, with a mean latency of 108 weeks (5 of 6 evaluable patients), and 22% for the 30-Gy/5-Gy fraction group, with an average latency of 191 weeks (4 of 18 evaluable patients) (P = 0.018). For AVMs that remained at 14 cm3 or more after embolization (5 of 6 patients), the obliteration rate remained 80% (4 of 5 patients) for the 7-Gy cohort and dropped to 9% for the 5-Gy cohort. A cumulative hazard plot revealed a 7.2-fold greater likelihood of obliteration with the 42-Gy/7-Gy fraction protocol (P = 0.0001), which increased to a 17-fold greater likelihood for postembolization AVMs of 14 cm3 or more (P = 0.003). CONCLUSION: FSR achieves obliteration for AVMs at a threshold dose, including large residual niduses after embolization. With significant treatment-related morbidities, further investigation warrants a need for better three-dimensional target definition with higher dose conformality.

COMPARISON OF EARLY COMPLICATIONS FOR PATIENTS WITH CONVEXITY AND PARASAGITTAL MENINGIOMAS TREATED WITH EITHER STEREOTACTIC RADIOSURGERY OR FRACTIONATED STEREOTACTIC RADIOTHERAPY

Neurosurgery ◽  
2008 ◽  
Vol 62 (suppl_5) ◽  
pp. A19-A28 ◽  
Author(s):  
Michael R. Girvigian ◽  
Joseph C.T. Chen ◽  
Javad Rahimian ◽  
Michael J. Miller ◽  
Michael Tome
Keyword(s):  
Stereotactic Radiosurgery ◽  
Stereotactic Radiotherapy ◽  
Univariate Analysis ◽  
Tumor Location ◽  
Fractionated Stereotactic Radiotherapy ◽  
Tumor Control ◽  
Lesion Volume ◽  
Group A ◽  
Group B

ABSTRACT OBJECTIVE Patients with convexity and parasagittal (CPS) meningiomas treated with stereotactic radiosurgery (SRS) have been shown to be at risk for posttreatment symptomatic peritumoral edema (SPTE). We sought to analyze the pattern of this complication and compare it with the SPTE experienced in our patients treated with fractionated stereotactic radiotherapy. METHODS From January 2003 to October 2005, 32 patients with CPS meningiomas were treated. Thirty patients with a total of 38 lesions had sufficient follow-up for analysis. Group A (n = 14) patients were treated with single fraction SRS, and Group B (n = 16) patients were treated with fractionated stereotactic radiotherapy. The lesion volume was different between the two groups with the Group B median volume (7.46 cm3) being larger than that for Group A (2.84 cm3) (P = 0.0008). Conversely age, follow-up, sex, prior surgical events, number of lesions, tumor location, and atypical histology did not differ between these groups. The median marginal dose for patients in Group A was 14 Gy (range, 12.5–18 Gy). For Group B, six patients received a median marginal dose of 50.4 Gy in 28 fractions, and 10 patients received a marginal dose of 25 Gy in five fractions. RESULTS Seven of the 30 patients treated in this series developed posttreatment SPTE. The incidence of SPTE in Group A (six of 14 patients) was significantly higher than that in Group B (one of 16 patients) (P = 0.031). The median time to onset of SPTE in the six patients in Group A was 4 months. In Group B, one patient had onset of SPTE in 3 months. On univariate analysis, larger tumor volume (P = 0.0014) and tumor margin dose >14 Gy in patients undergoing SRS (P = 0.031) was associated with onset of SPTE. Age, previous surgery, and tumor location were not associated with onset of SPTE. CONCLUSION Despite larger lesion volumes, fractionated stereotactic radiotherapy is associated with less risk of posttreatment SPTE than SRS for patients with CPS meningiomas in our series. For patients treated with SRS, smaller volume and dose <14 Gy seems to be safe. Longer follow-up will be required to compare late complications and tumor control rates in these patients.

Endocrinological outcome after pituitary transposition (hypophysopexy) and adjuvant radiotherapy for tumors involving the cavernous sinus

2011 ◽  
Vol 115 (1) ◽  
pp. 55-62 ◽  
Author(s):  
Philipp Taussky ◽  
Ricky Kalra ◽  
Jeroen Coppens ◽  
Jahan Mohebali ◽  
Randy Jensen ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Stereotactic Radiotherapy ◽  
Pituitary Adenomas ◽  
Residual Tumor ◽  
Fractionated Stereotactic Radiotherapy ◽  
Normal Pituitary Gland ◽  
Radiotherapy Treatment

Object Stereotactic radiosurgery and fractionated stereotactic radiotherapy are commonly used in the treatment of residual or recurrent benign tumors of the skull base and cavernous sinus. A major risk associated with radiosurgical or radiotherapy treatment of residual or recurrent tumors adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors have used a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual tumor within the cavernous sinus. Here, the authors analyze the long-term endocrinological outcomes in patients with residual and recurrent tumors who undergo hypophysopexy and adjuvant radiosurgical or conformal fractionated radiotherapy treatment. Methods Pituitary transposition involves placement of a fat graft between the normal pituitary gland and residual tumor in the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and the graft is interposed between the pituitary gland and the residual tumor. The residual tumor may then be treated with stereotactic radiosurgery or conformal fractionated radiation therapy. The authors evaluated endocrinological outcome, safety of the procedure, and postoperative complications in patients who underwent this procedure during a 7-year period. Results Hypophysopexy has been used in 34 patients with nonfunctioning pituitary adenomas (19), functional pituitary adenomas (8), chordomas (2), meningiomas (2), chondrosarcoma (1), hemangiopericytoma (1), or hemangioma (1) involving the sella and cavernous sinus. Follow-up (radiographic and endocrinological) has been performed yearly in all patients. Two patients experienced postoperative endocrine deficits before radiosurgery (1 transient), but none of the patients developed new hypopituitarism during the median 4-year follow-up (range 1–8 years) after radiosurgery or fractionated stereotactic radiotherapy. Conclusions The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery or radiotherapy and effectively reduces the incidence of radiation injury to the normal pituitary gland when compared with historical controls.

STEREOTACTIC RADIOSURGERY AND FRACTIONATED STEREOTACTIC RADIOTHERAPY FOR THE TREATMENT OF NONACOUSTIC CRANIAL NERVE SCHWANNOMAS

Neurosurgery ◽  
2008 ◽  
Vol 63 (4) ◽  
pp. 734-740 ◽  
Author(s):  
Timothy N. Showalter ◽  
Maria Werner-Wasik ◽  
Walter J. Curran ◽  
David P. Friedman ◽  
Xia Xu ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Stereotactic Radiotherapy ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Symptomatic Improvement ◽  
Fractionated Stereotactic Radiotherapy ◽  
Tumor Control ◽  
Median Dose ◽  
Significant Difference

ABSTRACT OBJECTIVE To review outcomes after fractionated stereotactic radiotherapy (FSR) and stereotactic radiosurgery (SRS) for nonacoustic cranial nerve schwannomas. METHODS We reviewed medical records of 39 patients who received FSR or SRS for nonacoustic cranial nerve schwannomas at our institution during the period from 1996 to 2007. RESULTS Tumors involved Cranial Nerves V (n = 19), III (n = 2), VI (n = 3), VII (n = 5), IX (n = 2), X (n = 5), and XII (n = 2) and the cavernous sinus (n = 1). Irradiation was performed after partial resection, biopsy, or no previous surgery in 16, 2, and 21 patients, respectively. Twenty-four patients received FSR, delivered in 1.8- to 2.0-Gy fractions to a median dose of 50.4 Gy (range, 45.0–54.0 Gy). Fifteen patients received SRS to a median dose of 12.0 Gy (range, 12–15 Gy). Mild acute toxicity occurred in 23% of the patients. The 2-year actuarial tumor control rate after FSR and SRS was 95%. The median follow-up period was 24 months. Changes in cranial nerve deficits after stereotactic irradiation were analyzed for patients with follow-up periods greater than 12 months (n = 26); cranial nerve deficits improved in 50%, were stable in 46%, and worsened in 4% of the patients. No significant difference was observed for FSR compared with SRS with regard to local control or to improvement of cranial nerve-related symptoms (P = 0.17). CONCLUSION SRS and FSR are both well-tolerated treatments for nonacoustic cranial nerve schwannomas, providing excellent tumor control and a high likelihood of symptomatic improvement.

Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma

2020 ◽  
Author(s):  
Alexander D. Sherry ◽  
Mohamed H. Khattab ◽  
Mark C. Xu ◽  
Patrick Kelly ◽  
Joshua L. Anderson ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Stereotactic Radiotherapy ◽  
Proportional Hazards ◽  
Binary Logistic Regression ◽  
Late Complications ◽  
Secondary Malignancy ◽  
Clinicopathologic Characteristics ◽  
Hypofractionated Stereotactic Radiotherapy ◽  
Cavernous Sinus Invasion

Abstract Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.

scholarly journals Short diameter may be a useful simple indicator of the tumor response in skull base meningiomas after conventionally fractionated stereotactic radiotherapy

2021 ◽  
Author(s):  
Keiichi Takehana ◽  
Daisuke Nakamura ◽  
Alshaymaa Abdelghaffar ◽  
Megumi Uto ◽  
Tomohiro Katagiri ◽  
...  
Keyword(s):  
Skull Base ◽  
Stereotactic Radiotherapy ◽  
Tumor Volume ◽  
Tumor Response ◽  
Fractionated Stereotactic Radiotherapy ◽  
Skull Base Meningioma ◽  
Skull Base Meningiomas ◽  
Simple Indicator ◽  
Conventionally Fractionated

Abstract Objectives The purpose of this study was to assess the radiological change patterns in skull base meningiomas after conventionally fractionated stereotactic radiotherapy (CFSRT) to determine a simple and valid method to assess the tumor response. Materials and methods Forty-one patients with a benign skull base meningioma treated by CFSRT from March 2007 to August 2015 were retrospectively evaluated. We measured tumor volume (TV), long-axis diameter (LD), and short-axis diameter (SD) on both pre-treatment images and follow-up images of 1, 3, and 5 years after CFSRT, respectively. The paired t test was used to detect differences in the LD and SD change rates. Spearman’s correlation coefficients were calculated to evaluate relationships between the TV and the diameters changes. Results The number of available follow-up MRIs that was performed at 1, 3, and 5 years after the CFSRT was 41 (100%), 34 (83%), and 23 (56%), respectively. The change rates of SD were significantly higher than those of LD at every time point and more strongly correlated with the change rates of tumor volume at 3 and 5 years after CFSRT. Conclusions SD may be useful as a simple indicator of the tumor response for skull base meningioma after CFSRT. Key Points • The change rate in short-axis diameter is a useful and simple indicator of the response of skull base meningioma to conventionally fractionated stereotactic radiotherapy. • Conventionally fractionated stereotactic radiotherapy for skull base meningioma achieved excellent 5-year local control.

Fractionated Stereotactic Radiotherapy for Pituitary Adenomas

Neurosurgery ◽  
2015 ◽  
Vol 79 (3) ◽  
pp. 406-417 ◽  
Author(s):  
Sean M. Barber ◽  
Bin S. Teh ◽  
David S. Baskin
Keyword(s):  
Stereotactic Radiotherapy ◽  
Pituitary Adenomas ◽  
Progression Free Survival ◽  
Hormonal Control ◽  
Fractionated Stereotactic Radiotherapy ◽  
Small Series ◽  
Early Results ◽  
Nonfunctional Pituitary Adenomas

Abstract BACKGROUND Early results of postoperative fractionated stereotactic radiotherapy (FSRT) for functional and nonfunctional pituitary adenomas appear promising, but the majority of available evidence draws from small series with insufficient follow-up data to draw meaningful conclusions. OBJECTIVE To evaluate the long-term outcomes of a large series of patients undergoing FSRT for both functional and nonfunctional pituitary adenomas with the Novalis system (Brain LAB, Heimstetten, Germany). METHODS Chart data for 75 consecutive patients undergoing FSRT for a pituitary tumor (21 functional and 54 nonfunctional adenomas) at our institution between January 2004 and June 2013 were reviewed. RESULTS Radiographic progression-free survival was 100% over a mean of 47.8 months of radiographic follow-up (range, 12.0-131.2 months). Hormonal normalization was seen in 69.2% of patients with functional adenomas after FSRT, whereas 30.8% experienced partial hormonal control. Mild, grade I acute adverse effects were observed during radiotherapy treatment in 36 patients (48%), and objective, persistent worsening of vision occurred in a single patient (1.5%) after FSRT. New hormonal deficits were seen in 28.0% of patients after FSRT. Radiographic responses were inversely related to tumor volume. CONCLUSION FSRT delivers radiographic and functional outcomes similar to those seen with stereotactic radiosurgery and conventional radiotherapy with less resultant toxicity. FSRT is most beneficial for smaller tumors (those <3 cm in diameter).

scholarly journals Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes

2014 ◽  
Vol 14 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Matthew B. Potts ◽  
Sunil A. Sheth ◽  
Jonathan Louie ◽  
Matthew D. Smyth ◽  
Penny K. Sneed ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Target Volume ◽  
Neurological Deficits ◽  
Single Institution ◽  
Risks And Benefits ◽  
Scale Scores ◽  
Time Of Presentation

Object Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. Methods The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. Results A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm3 (range 0.09–62.3 cm3), and median prescription marginal dose used was 17.5 Gy (range 12–20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18–20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%–37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0–2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. Conclusions A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.

scholarly journals Radiosurgery and stereotactic radiotherapy with cyberknife system for meningioma treatment

2017 ◽  
Vol 31 (1) ◽  
pp. 18-26 ◽  
Author(s):  
Rossella Di Franco ◽  
Valentina Borzillo ◽  
Vincenzo Ravo ◽  
Sara Falivene ◽  
Francesco Jacopo Romano ◽  
...  
Keyword(s):  
Disease Control ◽  
Stereotactic Radiosurgery ◽  
Local Control ◽  
Stereotactic Radiotherapy ◽  
Histological Grade ◽  
Fractionated Stereotactic Radiotherapy ◽  
Subtotal Resection ◽  
Local Disease ◽  
Local Disease Control ◽  
The Impact

Objective The aim of this work was to evaluate the impact of stereotactic radiosurgery/fractionated stereotactic radiotherapy with the Cyberknife system on local disease control, clinical outcome and toxicity in patients with meningioma, according to the site and histological grade of lesion. From January 2013 to April 2017, 52 patients with intracranial meningiomas were treated with the Cyberknife system. Twenty-four patients had undergone previous surgery: 38% gross total resection, 10% subtotal resection; 27 patients underwent no surgery; 22 patients had a recurrence of meningioma. Methods Radiosurgery was used for lesions smaller than 2 cm, stereotactic radiotherapy for lesions larger than 2 cm, or smaller but close to a critical site such as the optical chiasm, optic pathway or brainstem. Results Local control and clinical outcomes were analysed. Median follow-up was 20 months: six patients died, one after re-surgery died from post-surgical sepsis, three from heart disease. Progression-free survival had a mean value of 38.3 months and overall survival of 41.6 months. We evaluated at 12 months 28 patients (100% local control); at 24 months 19 patients (89% local control); at 36 months nine patients (89% local control). At baseline, 44/52 patients (85%) were symptomatic: 19 visual disorders, 17 motor disorders, six hearing disorders, 10 headache and six epilepsy. Visual symptoms remained unchanged in 52%, improved in 32%, resolved in 16%. Headache was improved in 40%, resolved in 10%, unchanged in 50%. Epilepsy was resolved in 17%, unchanged in 33%, worsened in 33%. Conclusions Stereotactic radiosurgery/fractionated stereotactic radiotherapy with Cyberknife provides a good local disease control, improving visual, hearing and motor symptoms.

Stereotactic radiosurgery for arteriovenous malformations: 1-year follow-up

1995 ◽  
pp. 527-528
Author(s):  
K. Suzuki ◽  
T. Hirai ◽  
A. Makino ◽  
A. Moriki ◽  
M. Yoshida ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations
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