"CNS-friendly" chemoradiotherapy in pediatric neuro-oncology

Stereotactically delivered cranial radiation therapy: a ten-year experience of linac-based radiosurgery in the UK

In 1989, linear accelerator (linac)-based cranial stereotactic radiation therapy ('radiosurgery') was introduced in the UK at St Bartholomew's Hospital; a new, relocatable stereotactic frame was first used at the same time, allowing fractionated stereotactic radiotherapy. In the first decade of clinical practice using this technology, some 200 patients with blood vessel tumours/malformations have been treated, together with another 200 suffering from other conditions. The usefulness of this technique for cerebral arteriovenous malformations (AVM) has been demonstrated, and also a significant cure rate for AVM of >3 cm diameter (which is larger than for those previously reported after treatment on the gamma unit), albeit attended by a higher complication rate. The epilepsy associated with AVM is much improved by successful radiotherapy. The usefulness of radiosurgery for glomus tumours has been confirmed and new data published on the efficacy of the technique for haemangioblastoma, with new radiation therapy strategies designed for patients with von Hippel-Lindau disease. The acoustic neuroma treatment results have included improvements in hearing (a result not reported in the gamma unit literature), which are ascribed to the lower internal dose gradient within the target volume. Fractionation will, it is argued, also lead to sparing of the special sensory cochlear nerve. The risks of radiosurgery to the brainstem for chordoma of the mid-clivus are reduced by using a 'spacer' technique for the prepontine space. For meningiomas involving the cavernous sinus, conventionally fractionated radiotherapy is recommended when the meningeal base diameter exceeds 3.0 cm and radiosurgery (utilizing fractionation where appropriate) is advised for smaller lesions. Thus far, radiosurgery indications for pituitary adenomas have been restricted to recurrences after conventional radiotherapy, usually those in the cavernous sinus. In therapy for recurrent craniopharyngioma, it is argued that fractionation delivered via the relocatable frame will be important, particularly when the disease envelops the optic chiasma. For semicystic/semisolid craniopharyngiomas, the stereotactic delivery of colloidal yttrium-90 into a cystic element is useful, while stereotactic radiosurgery is delivered to the solid component. Staff at this centre consider that radiosurgery for low-grade gliomas, perhaps as boost therapy after conventional fractionation, is worthy of more research. We have been extremely selective in the use of radiosurgery for brain metastases (2% of patients, compared with about 30% in some Gamma Knife units), but future indications may become broader, probably using it as a booster technique after whole-brain conventionally-fractionated radiotherapy. Positron emission tomography scanning, co-registered with magnetic resonance imaging, allows the 'boost' concept in radiosurgery to become a sophisticated and accurate reality. Post-radiosurgical sequelae have been placed within a standard framework classification. New observations are being made with regard to subacute reactions: late-responding intrinsic and extra-axial tumours may swell in the subacute period, prior to shrinkage, and be attended by symptomatic surrounding brain oedema.