scholarly journals Current Management and Image Review of Skull Base Chordoma: What the Radiologist Needs to Know

2021 ◽  
Vol 11 ◽  
pp. 46
Author(s):  
Erik Soule ◽  
Saif Baig ◽  
Peter Fiester ◽  
Adam Holtzman ◽  
Michael Rutenberg ◽  
...  
Keyword(s):  
Skull Base ◽  
Radiation Treatment ◽  
Critical Role ◽  
Disease Recurrence ◽  
Surgical Anatomy ◽  
Current Management ◽  
Treatment Changes ◽  
Slow Growing ◽  
Skull Base Chordoma

Chordomas of the skull-base are typically slow-growing, notochord-derived tumors that most commonly originate along the clivus. Skull base chordoma is treated with surgery and radiotherapy. Local recurrence approaches 50% at 10 years. Radiologists play a critical role in diagnosis, treatment planning, and follow-up. Surgeons and radiation oncologists rely on radiologists for pre-operative delineation of tumor and adjacent anatomy, identification of post-treatment changes and disease recurrence, and radiation treatment effects. This review provides an overview of clinical characteristics, surgical anatomy, indications for radiotherapy, identification of treatment complications, and patterns of disease recurrence for radiologists to provide value in the management of these lesions.

scholarly journals Patient Outcomes after Reirradiation of Small Skull Base Tumors using Stereotactic Body Radiotherapy, Intensity Modulated Radiotherapy, or Proton Therapy

2019 ◽  
Vol 81 (06) ◽  
pp. 638-644
Author(s):  
Sweet Ping Ng ◽  
He Wang ◽  
Courtney Pollard ◽  
Theresa Nguyen ◽  
Houda Bahig ◽  
...  
Keyword(s):  
Skull Base ◽  
Stereotactic Body Radiotherapy ◽  
Radiation Treatment ◽  
Intensity Modulated Radiotherapy ◽  
Treatment Modalities ◽  
Tumor Control ◽  
Skull Base Tumors ◽  
Intensity Modulated ◽  
Grade 3

Abstract Purpose The aim of this study was to evaluate outcomes of patients who received reirradiation for small skull base tumors utilizing either intensity modulated radiotherapy (IMRT), stereotactic body radiotherapy (SBRT), and proton radiotherapy (PRT). Methods Patients who received IMRT, SBRT or PRT reirradiation for recurrent or new small skull base tumors (< 60 cc) between April 2000 and July 2016 were identified. Those with < 3 months follow-up were excluded. Clinical outcomes and treatment toxicity were assessed. The Kaplan–Meier method was used to estimate the local control (LC), regional control (RC), distant control (DC), progression free survival (PFS), and overall survival (OS). Results Of the 75 patients eligible, 30 (40%) received SBRT, 30 (40%) received IMRT, and 15 (20%) received PRT. The median retreatment volume was 28 cc. The median reirradiation dose was 66 Gy in 33 fractions for IMRT/PRT, and 45 Gy in 5 fractions for SBRT. The median time to reirradiation was 41 months. With a median follow-up of 24 months, the LC, RC, DC, PFS, and OS rates were 84%, 79%, 82%, 60%, and 87% at 1 year, and 75%, 72%, 80%, 49%, and 74% at 2 years. There was no difference in OS between radiation modalities. The 1- and 2-year late Grade 3 toxicity rates were 3% and 11% respectively.. Conclusions Reirradiation of small skull base tumors utilizing IMRT, PRT, or SBRT provided good local tumor control and low rates of Grade 3 late toxicity. A prospective clinical trial is needed to guide selection of radiation treatment modalities.

scholarly journals Clinical Outcomes Following Dose-Escalated Proton Therapy for Skull-Base Chordoma

2021 ◽  
Vol 8 (1) ◽  
pp. 179-188
Author(s):  
Adam L. Holtzman ◽  
Ronny L. Rotondo ◽  
Michael S. Rutenberg ◽  
Daniel J. Indelicato ◽  
Alexandra De Leo ◽  
...  
Keyword(s):  
Overall Survival ◽  
Skull Base ◽  
Local Control ◽  
Subtotal Resection ◽  
High Dose ◽  
Disease Specific Survival ◽  
Total Resection ◽  
Skull Base Chordoma ◽  
Disease Specific

Abstract Purpose To evaluate the effectiveness of external-beam proton therapy (PT) on local control and survival in patients with skull-base chordoma. Materials and Methods We reviewed the medical records of patients with skull-base chordoma treated with definitive or adjuvant high-dose PT and updated their follow-up when feasible. We assessed overall survival, disease-specific survival, local control, and freedom from distant metastasis. Radiotherapy toxicities were scored using the Common Terminology Criteria for Adverse Events, version 4.0. Results A total 112 patients were analyzed, of whom 105 (94%) received PT and 7 (6%) received combined proton-photon therapy between 2007 and 2019. Eighty-seven patients (78%) underwent a subtotal resection, 22 (20%) a gross total resection, and 3 (3%) a biopsy alone. The median radiotherapy dose was 73.8 Gy radiobiologic equivalent (GyRBE; range, 69.6-74.4). Ninety patients (80%) had gross disease at radiotherapy and 7 (6%) were treated for locally recurrent disease following surgery. Median follow-up was 4.4 years (range, 0.4-12.6); for living patients, it was 4.6 years (range, 0.4-12.6), and for deceased patients, 4.1 years (range, 1.2-11.2). At 5 years after radiotherapy, the actuarial overall survival, disease-specific survival, local control, and freedom from distant metastasis rates were 78% (n = 87), 83% (n = 93), 74% (n = 83), and 99% (n = 111), respectively. The median time to local progression was 2.4 years (range, 0.8-7). Local control and disease-specific survival by resection status was 95% versus 70% (P = 0.28) and 100% versus 80% (P = 0.06) for gross total, versus subtotal, resection or biopsy alone, respectively. There were no serious acute toxicities (grade ≥ 3) related to radiotherapy. Conclusion High-dose PT alone or after surgical resection for skull-base chordoma reaffirms the favorable 5-year actuarial local control rate compared with conventional techniques with acceptable late-complication–free survival. Outcomes following gross total resection and adjuvant PT were excellent. Further follow-up of this cohort is necessary to better characterize long-term disease control and late toxicities.

scholarly journals Dosimetric analysis of local failures in skull-base chordoma and chondrosarcoma following pencil beam scanning proton therapy

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Lucas Basler ◽  
Robert Poel ◽  
Christina Schröder ◽  
Alessandra Bolsi ◽  
Antony Lomax ◽  
...  
Keyword(s):  
Skull Base ◽  
Proton Therapy ◽  
Pencil Beam ◽  
Beam Scanning ◽  
Pencil Beam Scanning ◽  
Dosimetric Analysis ◽  
Skull Base Chordoma ◽  
Patterns Of Recurrence ◽  
Initial Target

Abstract Background Despite combined modality treatment involving surgery and radiotherapy, a relevant proportion of skull-base chordoma and chondrosarcoma patients develop a local recurrence (LR). This study aims to analyze patterns of recurrence and correlate LR with a detailed dosimetric analysis. Methods 222 patients were treated with proton radiotherapy for chordoma (n = 151) and chondrosarcoma (n = 71) at the PSI between 1998 and 2012. All patients underwent surgery, followed by pencil-beam scanning proton therapy to a mean dose of 72.5 ± 2.2GyRBE. A retrospective patterns of recurrence analysis was performed: LR were contoured on follow-up MRI, registered with planning-imaging and the overlap with initial target structures (GTV, PTVhigh-dose, PTVlow-dose) was calculated. DVH parameters of planning structures and recurrences were calculated and correlated with LR using univariate and multivariate cox regression. Results After a median follow-up of 50 months, 35 (16%) LR were observed. Follow-up MRI imaging was available for 27 (77%) of these recurring patients. Only one (3.7%) recurrence was located completely outside the initial PTV (surgical pathway recurrence). The mean proportions of LR covered by the initial target structures were 48% (range 0–86%) for the GTV, 70% (range 0–100%) for PTVhigh and 83% (range 0–100%) for PTVlow. In the univariate analysis, the following DVH parameters were significantly associated with LR: GTV(V < 66GyRBE, p = 0.01), GTV(volume, p = 0.02), PTVhigh(max, p = 0.02), PTVhigh(V < 66GyRBE, p = 0.03), PTVhigh(V < 59GyRBE, p = 0.02), PTVhigh(volume, p = 0.01) and GTV(D95, p = 0.05). In the multivariate analysis, only histology (chordoma vs. chondrosarcoma, p = 0.01), PTVhigh(volume, p = 0.05) and GTV(V < 66GyRBE, p = 0.02) were independent prognostic factors for LR. Conclusion This study identified DVH parameters, which are associated with the risk of local recurrence after proton therapy using pencil-beam scanning for patients with skull-base chordoma and chondrosarcoma.

scholarly journals Long-term outcomes of grade I/II skull base chondrosarcoma: an insight into the role of surgery and upfront radiotherapy

2021 ◽  
Author(s):  
Hirotaka Hasegawa ◽  
Kunal Vakharia ◽  
Christopher S Graffeo ◽  
Matthew L Carlson ◽  
Bruce E Pollock ◽  
...  
Keyword(s):  
Skull Base ◽  
Radiation Treatment ◽  
Treatment Strategies ◽  
Tumor Grade ◽  
Salvage Radiotherapy ◽  
Tumor Control ◽  
Entire Group ◽  
Group A ◽  
Group B

Abstract PurposeTo clarify the need for post-operative radiation treatment in skull base chondrosarcomas (SBCs).MethodsA retrospective analysis of patients with grade I or II SBC. Patients were divided according to post-surgical treatment strategies: (A) planned upfront radiotherapy and (B) watchful waiting. Tumor control and survival were compared between the treatment groups. The median follow-up after resection was 105 months (range, 9-376).ResultsThirty-two patients (Grade 1, n = 16; Grade 2, n = 16) were included. The most frequent location was petroclival (21, 64%). A gross total resection (GTR) was achieved in 11 patients (34%). Fourteen (44%) underwent upfront radiotherapy (group A) whereas 18 (56%) were followed with serial MRI alone (group B). The tumor control rate for the entire group was 77% and 69% at 10- and 15-year, respectively. Upfront radiotherapy (P = 0.25), extent of resection (P = 0.11) or tumor grade (P = 0.83) did not affect tumor control. The majority of Group B patients with recurrent tumors (5/7) obtained tumor control with repeat resection (n = 2), salvage radiotherapy (n = 2), or a combination of both (n = 1). The 10-year disease-specific survival was 95% with no difference between the group A and B (P = 0.50). ConclusionFor patients with grade I/II SBC, a reasonable strategy is deferral of radiotherapy after maximum safe resection until tumor progression or recurrence. At that time, most patients can be successfully managed with salvage radiotherapy or surgery. Late recurrences may occur, and life-long follow-up is advisable.

scholarly journals RARE-40. OUTCOMES AFTER PROTON THERAPY FOR SKULL-BASE CHORDOMA: A PROSPECTIVE STUDY

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi230-vi230
Author(s):  
Adam Holtzman ◽  
Ronny Rotondo ◽  
Michael Rutenberg ◽  
Daniel Indelicato ◽  
Dinesh Rao ◽  
...  
Keyword(s):  
Skull Base ◽  
Local Control ◽  
Proton Therapy ◽  
High Dose ◽  
Free Survival ◽  
3 Dimensional ◽  
Grade 3 ◽  
Skull Base Chordoma ◽  
Cause Specific Survival

Abstract We evaluated treatment outcomes following definitive or adjuvant high-dose, image-guided proton therapy in 91 patients with skull-base chordoma enrolled on a prospective outcomes tracking protocol and treated between February 2007 and February 2018. The median age was 53 years (range, 22–78 years). Patients received passively scattered 3-dimensional conformal proton therapy to a median dose of 73.8 GyRBE (range, 69.6–75.6 GyRBE). Two patients received a component of intensity-modulated radiotherapy. Seventy percent (n=64) were men and 30% (n=27) were woman. Eighty-two percent (n=75) of patients had macroscopic disease at the time of radiotherapy; 18% (n=16) had undergone a macroscopic gross total resection. Overall survival, cause-specific survival, local control, and RT-related grade 3 toxicity-free survival were calculated. Proton therapy-related toxicities were scored using CTCAE v4.0. With a median follow-up of 3.7 years (range, 0.2–10 years), 26 patients experienced disease recurrence, including 26 local, 0 regional, and 1 distant recurrence. The median time to local progression was 2.2 years (range, 0.4–7.0 years). At the time of last follow-up, 66 patients were alive (56 with no evidence of disease progression) and 25 were deceased (18 with disease progression). There were no acute grade 3 toxicities related to the radiation therapy. The 4-year actuarial rates of overall survival, cause-specific survival, local control, and radiation therapy-related grade 3 toxicity-free survival were 83%, 87%, 76% and 83%, respectively. Definitive or adjuvant high-dose passively scattered 3-dimensional conformal proton therapy for skull-base chordoma provides acceptable local control, comparing favorably to historic photon data, with no acute grade ≥3 radiation-related toxicity and an acceptable rate of grade ≥3 late toxicity. Further follow-up of this cohort is necessary to better characterize long-term disease control and late toxicities.

Recurrence patterns in esophageal cancer patients undergoing curative trimodality therapy.

2017 ◽  
Vol 35 (4_suppl) ◽  
pp. 195-195
Author(s):  
Edwin Chan ◽  
Catherine Vanderwater ◽  
Rachel Woo ◽  
Charles Cho ◽  
Jason Wong ◽  
...  
Keyword(s):  
Esophageal Cancer ◽  
Cancer Patients ◽  
Locoregional Recurrence ◽  
Radiation Treatment ◽  
Disease Free Survival ◽  
Disease Recurrence ◽  
Trimodality Therapy ◽  
Node Positive ◽  
Clinically Node Positive

195 Background: To document pattern of recurrence and its relationship to the radiation treatment volume in esophageal cancer patients treated with trimodality therapy. Methods: Patients with adenocarcinoma or squamous cell carcinoma (SCC) of the esophagus, T1-4N0-3 (AJCC 7thEd.) treated with chemoradiation (CRT) and esophageal resection between June 2010 and November 2015 participated in a prospective cohort study. Patients were planned using 4DCT and IMRT or VMAT. GTV and CTV were contoured on 4D exhale, inhale phases and voluntary exhale helical CT. CTV margins were 3-4cm superiorly and inferiorly, and 1cm circumferentially. CTVs were combined to form the ITV. PTV margin was 0.5cm. Site of first disease recurrence was classified as in-field (within 90% isodose), marginal (between 50-90%), or out-of-field (outside 50%). Results: Fifty-eight patients participated. Median age was 66 years (range: 40–78); 52 males: 6 females. 49 had adenocarcinoma, 7 SCC, and 2 mixed histology. 52 (90%) had clinically node positive disease. 31 received concurrent radiation 45-50Gy/25fr with Cisplatin/5FU and 27 received 41.4Gy/23fr with Carboplatin/Paclitaxel (CROSS protocol). 15 (27%) achieved a pathological complete response (pCR). Median follow up was 1.6 years (range: 0.2-4.8), 2-year overall survival 71%, disease-free survival 59%, median survival 4.4 years and median time to relapse 2.3 years. 17 patients (29%) had disease recurrence of which, at initial diagnosis, all were clinically node positive and 3 had pCR after CRT. Five developed locoregional recurrence (2 anastomatic, 3 locoregional nodes), 4 both locoregional and distant, and 8 distant recurrence alone. Of 9 patients with locoregional recurrence, 1 had in-field, 6 out-of-field and 2 had disease traversing in and out-of-field areas. 4 of 17 (24%) were treated with curative intent (1 surgery, 3 CRT) and all were alive at the latest follow up (time from first recurrence: 6 to 49 months). Conclusions: Survival and recurrence outcomes in this small cohort are similar to those reported in the literature. Only a small proportion of patients experienced in-field relapse. Of those who relapsed, 24% received curative salvage therapy.

scholarly journals Skull base chordoma treated with proton therapy: A systematic review

2019 ◽  
Vol 10 ◽  
pp. 96 ◽  
Author(s):  
Mohammed Alahmari ◽  
Yasin Temel
Keyword(s):  
Side Effects ◽  
Skull Base ◽  
Proton Therapy ◽  
Search Algorithm ◽  
High Energy ◽  
Recurrence Rates ◽  
Number Of Patients ◽  
The Mean ◽  
Skull Base Chordoma

Background: Chordoma located in the skull base is usually a challenging surgical condition. It is often not possible to achieve gross total resection. Residual tumors have been treated with adjuvant focal radiation therapy employing high-energy particles most commonly through proton beam. In this review, we systematically analyzed indications and outcomes of this treatment with respect to local control rates of the lesion and factors determining recurrence of skull base chordomas. In addition, we collected data on treatment-associated radiation-induced side effects. Methods: In line with the PRISMA guidelines, the authors performed a literature search algorithm for relevant articles using three databases: PubMed, Embase, and Cochrane. Inclusion and exclusion criteria were applied to evaluate all identified studies published between 1980 and 2018. Results: Our review included 11 studies for analysis (n = 511 patients). The mean age of the study population was 47.3 ± 5.8 years. The mean dose of postsurgical irradiation at the time of initial treatment was 71.1 ± 3.1 Gy. The mean follow-up duration was 45.0 ± 17.5 months. Within this follow-up duration, recurrence occurred in 26.8% of the patients. The mean time to recurrence was 34.5 ± 15.2 months. A significant number of patients experienced side effects varying from Grade 1 (mild dermatitis) to Grade 4 (temporal lobe necrosis and visual disorders). Conclusion: Despite advances in proton therapy, recurrence rates in skull base chordoma remain high. The toxicity of proton therapy may be more prevalent than generally thought. Unfortunately, there is substantial variation in the methods of data reporting.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Posterior Petrosal Approach

2019 ◽  
Author(s):  
Christopher Graffeo ◽  
Maria Peris-Celda ◽  
Avital Perry ◽  
Lucas Carlstrom ◽  
Colin Driscoll ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Anatomy

Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 113-119 ◽  
Author(s):  
D. Hung-Chi Pan ◽  
Wan-Yuo Guo ◽  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Yue-Cune Chang ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Treatment ◽  
Gamma Knife Radiosurgery ◽  
Consecutive Series ◽  
Content Type ◽  
Obliteration Rate ◽  
Complete Obliteration ◽  
Fine Print

Object. A consecutive series of 240 patients with arteriovenous malformations (AVMs) treated by gamma knife radiosurgery (GKS) between March 1993 and March 1999 was evaluated to assess the efficacy and safety of radiosurgery for cerebral AVMs larger than 10 cm3 in volume. Methods. Seventy-six patients (32%) had AVM nidus volumes of more than 10 cm3. During radiosurgery, targeting and delineation of AVM nidi were based on integrated stereotactic magnetic resonance (MR) imaging and x-ray angiography. The radiation treatment was performed using multiple small isocenters to improve conformity of the treatment volume. The mean dose inside the nidus was kept between 20 Gy and 24 Gy. The margin dose ranged between 15 to 18 Gy placed at the 55 to 60% isodose centers. Follow up ranged from 12 to 73 months. There was complete obliteration in 24 patients with an AVM volume of more than 10 cm3 and in 91 patients with an AVM volume of less than 10 cm3. The latency for complete obliteration in larger-volume AVMs was significantly longer. In Kaplan—Meier analysis, the complete obliteration rate in 40 months was 77% in AVMs with volumes between 10 to 15 cm3, as compared with 25% for AVMs with a volume of more than 15 cm3. In the latter, the obliteration rate had increased to 58% at 50 months. The follow-up MR images revealed that large-volume AVMs had higher incidences of postradiosurgical edema, petechiae, and hemorrhage. The bleeding rate before cure was 9.2% (seven of 76) for AVMs with a volume exceeding 10 cm3, and 1.8% (three of 164) for AVMs with a volume less than 10 cm3. Although focal edema was more frequently found in large AVMs, most of the cases were reversible. Permanent neurological complications were found in 3.9% (three of 76) of the patients with an AVM volume of more than 10 cm3, 3.8% (three of 80) of those with AVM volume of 3 to 10 cm3, and 2.4% (two of 84) of those with an AVM volume less than 3 cm3. These differences in complications rate were not significant. Conclusions. Recent improvement of radiosurgery in conjunction with stereotactic MR targeting and multiplanar dose planning has permitted the treatment of larger AVMs. It is suggested that gamma knife radiosurgery is effective for treating AVMs as large as 30 cm3 in volume with an acceptable risk.

Stereotactic radiation treatment planning and follow-up studies involving fused multimodality imaging

2004 ◽  
Vol 101 (Supplement3) ◽  
pp. 326-333 ◽  
Author(s):  
Klaus D. Hamm ◽  
Gunnar Surber ◽  
Michael Schmücking ◽  
Reinhard E. Wurm ◽  
Rene Aschenbach ◽  
...  
Keyword(s):  
Image Fusion ◽  
Treatment Planning ◽  
Radiation Treatment ◽  
Data Sets ◽  
Slice Thickness ◽  
Radiation Treatment Planning ◽  
Content Type ◽  
Follow Up Studies ◽  
Fine Print

Object. Innovative new software solutions may enable image fusion to produce the desired data superposition for precise target definition and follow-up studies in radiosurgery/stereotactic radiotherapy in patients with intracranial lesions. The aim is to integrate the anatomical and functional information completely into the radiation treatment planning and to achieve an exact comparison for follow-up examinations. Special conditions and advantages of BrainLAB's fully automatic image fusion system are evaluated and described for this purpose. Methods. In 458 patients, the radiation treatment planning and some follow-up studies were performed using an automatic image fusion technique involving the use of different imaging modalities. Each fusion was visually checked and corrected as necessary. The computerized tomography (CT) scans for radiation treatment planning (slice thickness 1.25 mm), as well as stereotactic angiography for arteriovenous malformations, were acquired using head fixation with stereotactic arc or, in the case of stereotactic radiotherapy, with a relocatable stereotactic mask. Different magnetic resonance (MR) imaging sequences (T1, T2, and fluid-attenuated inversion-recovery images) and positron emission tomography (PET) scans were obtained without head fixation. Fusion results and the effects on radiation treatment planning and follow-up studies were analyzed. The precision level of the results of the automatic fusion depended primarily on the image quality, especially the slice thickness and the field homogeneity when using MR images, as well as on patient movement during data acquisition. Fully automated image fusion of different MR, CT, and PET studies was performed for each patient. Only in a few cases was it necessary to correct the fusion manually after visual evaluation. These corrections were minor and did not materially affect treatment planning. High-quality fusion of thin slices of a region of interest with a complete head data set could be performed easily. The target volume for radiation treatment planning could be accurately delineated using multimodal information provided by CT, MR, angiography, and PET studies. The fusion of follow-up image data sets yielded results that could be successfully compared and quantitatively evaluated. Conclusions. Depending on the quality of the originally acquired image, automated image fusion can be a very valuable tool, allowing for fast (∼ 1–2 minute) and precise fusion of all relevant data sets. Fused multimodality imaging improves the target volume definition for radiation treatment planning. High-quality follow-up image data sets should be acquired for image fusion to provide exactly comparable slices and volumetric results that will contribute to quality contol.

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