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Loganovsky KN, Marazziti D, Fedirko PA, Kuts KV, Antypchuk KY, Perchuk IV, Babenko TF, Loganovska TK, Kolosynska OO, Kreinis GY, Gresko MV, Masiuk SV, Mucci F, Zdorenko LL, Della Vecchia A, Zdanevich NA, Garkava NA, Dorichevska RY, Vasilenko ZL, Kravchenko VI, Drosdova NV. Radiation-Induced Cerebro-Ophthalmic Effects in Humans. Life (Basel) 2020; 10:E41. [PMID: 32316206 PMCID: PMC7235763 DOI: 10.3390/life10040041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/08/2020] [Accepted: 04/12/2020] [Indexed: 12/15/2022] Open
Abstract
Exposure to ionizing radiation (IR) could affect the human brain and eyes leading to both cognitive and visual impairments. The aim of this paper was to review and analyze the current literature, and to comment on the ensuing findings in the light of our personal contributions in this field. The review was carried out according to the PRISMA guidelines by searching PubMed, Scopus, Embase, PsycINFO and Google Scholar English papers published from January 2000 to January 2020. The results showed that prenatally or childhood-exposed individuals are a particular target group with a higher risk for possible radiation effects and neurodegenerative diseases. In adulthood and medical/interventional radiologists, the most frequent IR-induced ophthalmic effects include cataracts, glaucoma, optic neuropathy, retinopathy and angiopathy, sometimes associated with specific neurocognitive deficits. According to available information that eye alterations may induce or may be associated with brain dysfunctions and vice versa, we propose to label this relationship "eye-brain axis", as well as to deepen the diagnosis of eye pathologies as early and easily obtainable markers of possible low dose IR-induced brain damage.
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Affiliation(s)
- Konstantin N. Loganovsky
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale Section of Psychiatry, University of Pisa, Via Roma, 67, I 56100 Pisa, Italy; (F.M.); (A.D.V.)
| | - Pavlo A. Fedirko
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Kostiantyn V. Kuts
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Katerina Y. Antypchuk
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Iryna V. Perchuk
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Tetyana F. Babenko
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Tetyana K. Loganovska
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Olena O. Kolosynska
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - George Y. Kreinis
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Marina V. Gresko
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Sergii V. Masiuk
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Federico Mucci
- Dipartimento di Medicina Clinica e Sperimentale Section of Psychiatry, University of Pisa, Via Roma, 67, I 56100 Pisa, Italy; (F.M.); (A.D.V.)
- Dipartimento di Biochimica Biologia Molecolare, University of Siena, 53100 Siena, Italy
| | - Leonid L. Zdorenko
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Alessandra Della Vecchia
- Dipartimento di Medicina Clinica e Sperimentale Section of Psychiatry, University of Pisa, Via Roma, 67, I 56100 Pisa, Italy; (F.M.); (A.D.V.)
| | - Natalia A. Zdanevich
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Natalia A. Garkava
- Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine, 9 Vernadsky Street, 49044 Dnipro, Ukraine;
| | - Raisa Y. Dorichevska
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Zlata L. Vasilenko
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Victor I. Kravchenko
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
| | - Nataliya V. Drosdova
- National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine, 53 Illyenko Street, 04050 Kyiv, Ukraine; (K.N.L.); (P.A.F.); (K.V.K.); (K.Y.A.); (I.V.P.); (T.F.B.); (T.K.L.); (O.O.K.); (G.Y.K.); (M.V.G.); (S.V.M.); (L.L.Z.); (N.A.Z.); (R.Y.D.); (Z.L.V.); (V.I.K.); (N.V.D.)
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Stereotactic radiotherapy for small and very small tumours (≤1 to ≤3 cc): evaluation of the influence of volumetric-modulated arc therapy in comparison to dynamic conformal arc therapy and 3D conformal radiotherapy as a function of flattened and unflattened beam models. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s146039691900102x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractPurpose:The objective of this article is to evaluate the dosimetric efficacy of volumetric modulated arc therapy (VMAT) in comparison to dynamic conformal arc therapy (DCAT) and 3D conformal radiotherapy (3DCRT) for very small volume (≤1 cc) and small volume (≤3 cc) tumours for flattened (FF) and unflattened (FFF) 6 MV beams.Materials and methods:A total of 21 patients who were treated with single-fraction stereotactic radiosurgery, using either VMAT, DCAT or 3DCRT, were included in this study. The volume categorisation was seven patients each in <1, 1–2 and 2–3 cc volume. The treatment was planned with 6 MV FF and FFF beams using three different techniques: VMAT/Rapid Arc (RA) (RA_FF and RA_FFF), dynamic conformal arc therapy (DCA_FF and DCA_FFF) and 3DCRT (Static_FF and Static_FFF). Plans were evaluated for target coverage (V100%), conformity index, homogeneity index, dose gradient for 50% dose fall-off, total MU and MU/dose ratio [intensity-modulated radiotherapy (IMRT) factor], normal brain receiving >12 Gy dose, dose to the organ at risk (OAR), beam ON time and dose received by 12 cc of the brain.Result:The average target coverage for all plans, all tumour volumes (TVs) and delivery techniques is 96·4 ± 4·5 (range 95·7 ± 6·1–97·5 ± 2·9%). The conformity index averaged over all volume ranges <1, 2, 3 cc> varies between 0·55 ± 0·08 and 0·68 ± 0·04 with minimum and maximum being exhibited by DCA_FFF for 1 cc and Static_FFF/RA_FFF for 3 cc tumours, respectively. Mean IMRT factor averaged over all volume ranges for RA_FF, DCA_FF and Static_FF are 3·5 ± 0·8, 2·0 ± 0·2 and 2·0 ± 0·2, respectively; 50% dose fall-off gradient varies in the range of 0·33–0·42, 0·35–0·40 and 0·38–0·45 for 1, 2 and 3 cc tumours, respectively.Conclusion:This study establishes the equivalence between the FF and FFF beam models and different delivery techniques for stereotactic radiosurgery in small TVs in the range of ≤1 to ≤3 cc. Dose conformity, heterogeneity, dose fall-off characteristics and OAR doses show no or very little variation. FFF could offer only limited time advantage due to excess dose rate over an FF beam.
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Loganovsky KN, Fedirko PA, Kuts KV, Marazziti D, Antypchuk KY, Perchuk IV, Babenko TF, Loganovska TK, Kolosynska OO, Kreinis GY, Gresko MV, Masiuk SV, Zdorenko LL, Zdanevich NA, Garkava NA, Dorichevska RY, Vasilenko ZL, Kravchenko VI, Drosdova NV, Yefimova YV. BRAIN AND EYE AS POTENTIAL TARGETS FOR IONIZING RADIATION IMPACT. Part І. THE CONSEQUENCES OF IRRADIATION OF THE PARTICIPANTS OF THE LIQUIDATION OF THE CHORNOBYL ACCIDENT. PROBLEMY RADIAT︠S︡IĬNOÏ MEDYT︠S︡YNY TA RADIOBIOLOHIÏ 2020; 25:90-129. [PMID: 33361831 DOI: 10.33145/2304-8336-2020-25-90-129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Exposure to ionizing radiation could affect the brain and eyes leading to cognitive and vision impairment, behavior disorders and performance decrement during professional irradiation at medical radiology, includinginterventional radiological procedures, long-term space flights, and radiation accidents. OBJECTIVE The objective was to analyze the current experimental, epidemiological, and clinical data on the radiation cerebro-ophthalmic effects. MATERIALS AND METHODS In our analytical review peer-reviewed publications via the bibliographic and scientometric bases PubMed / MEDLINE, Scopus, Web of Science, and selected papers from the library catalog of NRCRM - theleading institution in the field of studying the medical effects of ionizing radiation - were used. RESULTS The probable radiation-induced cerebro-ophthalmic effects in human adults comprise radiation cataracts,radiation glaucoma, radiation-induced optic neuropathy, retinopathies, angiopathies as well as specific neurocognitive deficit in the various neuropsychiatric pathology including cerebrovascular pathology and neurodegenerativediseases. Specific attention is paid to the likely stochastic nature of many of those effects. Those prenatally and inchildhood exposed are a particular target group with a higher risk for possible radiation effects and neurodegenerative diseases. CONCLUSIONS The experimental, clinical, epidemiological, anatomical and pathophysiological rationale for visualsystem and central nervous system (CNS) radiosensitivity is given. The necessity for further international studieswith adequate dosimetric support and the follow-up medical and biophysical monitoring of high radiation riskcohorts is justified. The first part of the study currently being published presents the results of the study of theeffects of irradiation in the participants of emergency works at the Chornobyl Nuclear Power Plant (ChNPP).
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Affiliation(s)
- K N Loganovsky
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - P A Fedirko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - K V Kuts
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - D Marazziti
- Dipartimento di Medicina Clinica e Sperimentale Section of Psychiatry, University of Pisa, Via Roma, 67, I 56100, Pisa, Italy
| | - K Yu Antypchuk
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - I V Perchuk
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - T F Babenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - T K Loganovska
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - O O Kolosynska
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - G Yu Kreinis
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - M V Gresko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - S V Masiuk
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - L L Zdorenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - N A Zdanevich
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - N A Garkava
- State Institution «Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine», 9 Vernadsky Street, Dnipro, 49044, Ukraine
| | - R Yu Dorichevska
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - Z L Vasilenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - V I Kravchenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - N V Drosdova
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
| | - Yu V Yefimova
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Illyenko Street, Kyiv, 04050, Ukraine
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Standardization of volumetric modulated arc therapy‐based frameless stereotactic technique using a multidimensional ensemble‐aided knowledge‐based planning. Med Phys 2019; 46:1953-1962. [DOI: 10.1002/mp.13470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/31/2022] Open
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Kohyama S, Uematsu M, Ishihara S, Shima K, Tamai S, Kusano S. An Experience of Stereotactic Radiation Therapy for Primary Intracranial Choriocarcinoma. TUMORI JOURNAL 2018; 87:162-5. [PMID: 11504371 DOI: 10.1177/030089160108700310] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report on a patient with choriocarcinoma in the pineal region who was successfully treated with stereotactic radiation therapy (SRT). The increased level of serum human chorionic gonadotropin (HCG) was lowered during chemotherapy with etoposide, cisplatin, and ifosfamide. However, HCG was not normalized and magnetic resonance images still showed an enhanced tumor mass with gadolinium. The patient underwent SRT of 40 Gy at an 80% isodose line per 10 fractions over'two weeks, followed by conventional craniospinal irradiation of 32.4 Gy. The level of HCG dropped below the detection limit. The patient has been in good condition for more than four years after the completion of treatment, without any signs of recurrence. We propose SRT as a valid treatment option for malignant germ cell tumors in the pineal region.
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Affiliation(s)
- S Kohyama
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan.
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Graffeo CS, Perry A, Link MJ, Daniels DJ. Pediatric Craniopharyngiomas: A Primer for the Skull Base Surgeon. J Neurol Surg B Skull Base 2018; 79:65-80. [PMID: 29404243 PMCID: PMC5796826 DOI: 10.1055/s-0037-1621738] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pediatric craniopharyngioma is a rare sellar-region epithelial tumor that, in spite of its typically benign pathology, has the potential to be clinically devastating, and presents a host of formidable management challenges for the skull base surgeon. Strategies in craniopharyngioma care have been the cause of considerable controversy, with respect to both philosophical and technical issues. Key questions remain unresolved, and include optimizing extent-of-resection goals; the ideal radiation modality and its role as an alternative, adjuvant, or salvage treatment; appropriate indications for expanded endoscopic endonasal surgery as an alternative to transcranial microsurgery; risks and benefits of skull base techniques in a pediatric population; benefits of and indications for intracavitary therapies; and the preferred management of common treatment complications. Correspondingly, we sought to review the preceding basic science and clinical outcomes literature on pediatric craniopharyngioma, so as to synthesize overarching recommendations, highlight major points of evidence and their conflicts, and assemble a general algorithm for skull base surgeons to use in tailoring treatment plans to the individual patient, tumor, and clinical course. In general terms, we concluded that safe, maximal, hypothalamic-sparing resection provides very good tumor control while minimizing severe deficits. Endoscopic endonasal, intraventricular, and transcranial skull base technique all have clear roles in the armamentarium, alongside standard craniotomies; these roles frequently overlap, and may be further optimized by using the approaches in adaptive combinations. Where aggressive subtotal resection is achieved, patients should be closely followed, with radiation initiated at the time of progression or recurrence-ideally via proton beam therapy, although three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and stereotactic radiosurgery are very appropriate in a range of circumstances, governed by access, patient age, disease architecture, and character of the recurrence. Perhaps most importantly, outcomes appear to be optimized by consolidated, multidisciplinary care. As such, we recommend treatment in highly experienced centers wherever possible, and emphasize the importance of longitudinal follow-up-particularly given the high incidence of recurrences and complications in a benign disease that effects a young patient population at risk of severe morbidity from hypothalamic or pituitary injury in childhood.
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Affiliation(s)
| | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David J. Daniels
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Müller HL, Merchant TE, Puget S, Martinez-Barbera JP. New outlook on the diagnosis, treatment and follow-up of childhood-onset craniopharyngioma. Nat Rev Endocrinol 2017; 13:299-312. [PMID: 28155902 DOI: 10.1038/nrendo.2016.217] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Childhood-onset craniopharyngiomas are rare embryonic tumours of low-grade histological malignancy. Novel insights into the molecular pathogenesis of human adamantinomatous craniopharyngioma have started to unveil the possibility of testing novel treatments targeting pathogenic pathways. Hypothalamic involvement and/or treatment-related lesions result in impaired physical and social functionality and in severe neuroendocrine sequelae. Quality of survival in patients with craniopharyngioma with hypothalamic involvement is impaired by severe obesity, physical fatigue and non-optimal psychosocial development. Patients with craniopharyngioma involving hypothalamic structures have reduced 20-year overall survival, but overall and progression-free survival are not related to the degree of surgical resection. Irradiation is effective in the prevention of tumour progression and recurrence. For favourably localized craniopharyngiomas, the preferred treatment of choice is to attempt complete resection with preservation of visual, hypothalamic and pituitary function. For unfavourably localized tumours in close proximity to optic and/or hypothalamic structures, a radical neurosurgical strategy attempting complete resection is not recommended owing to potential severe sequelae. As expertise has been shown to have an impact on post-treatment morbidity, medical societies should establish criteria for adequate professional expertise for the treatment of craniopharyngioma. On the basis of these criteria, health authorities should organize the certification of centres of excellence that are authorized to treat and care for patients with this chronic disease.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology and Oncology, Klinikum Oldenburg AöR, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, Germany
| | - Thomas E Merchant
- Division of Radiation Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105-3678, USA
| | - Stephanie Puget
- Service de Neurochirurgie, Hôpital Necker-Enfants Malades, Sorbonne Paris Cité, 149 Rue de Sèvres, 75015 Paris, France
| | - Juan-Pedro Martinez-Barbera
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, University College London (UCL) Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
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Safety and efficacy of fractionated stereotactic radiotherapy and stereotactic radiosurgery for treatment of pituitary adenomas: A systematic review and meta-analysis. J Neurol Sci 2016; 372:110-116. [PMID: 28017195 DOI: 10.1016/j.jns.2016.11.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/11/2016] [Accepted: 11/13/2016] [Indexed: 01/11/2023]
Abstract
Accumulated studies have not provided conclusive evidence in regards to the comparative efficacy and safety of fractionated stereotactic radiotherapy and stereotactic radiosurgery for treatment of pituitary adenomas. To address this issue, we performed a meta-analysis with eight studies identified from Medline, PubMed, Cochrane, Google Scholar, and published up to September 17, 2015. Eligible studies reported the disease control rate, endocrine cure rate (for functional adenomas), the rate of occurrence of new-onset hypopituitarism, and visual disturbance rate in patients treated with either stereotactic radiosurgery or fractionated stereotactic radiotherapy. Eight studies enrolled a total of 634 patients with pituitary adenoma, 273 patients underwent a stereotactic radiosurgery and 361 patients underwent fractionated stereotactic radiotherapy. No significant differences were found in efficacy measures, such as disease control rate and endocrine cure rate, between stereotactic radiosurgery and fractionated stereotactic radiotherapy (OR=1.156, p=0.666; OR=0.659, p=0.153, respectively). Additionally, meta-analysis of safety measures, such as the rate of new-onset hypopituitarism and visual disturbance rate, did not show significant differences between different treatments (OR=1.365, p=0.469; OR=0.872, p=0.845 respectively). In conclusion, both stereotactic radiosurgery and fractionated stereotactic radiotherapy have comparable efficacy and safety in the management of pituitary adenoma patients.
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Shields LB, Coons JM, Dedich C, Ragains M, Scalf K, Vitaz TW, Spalding AC. Improvement of therapeutic index for brain tumors with daily image guidance. Radiat Oncol 2013; 8:283. [PMID: 24295338 PMCID: PMC4222040 DOI: 10.1186/1748-717x-8-283] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 11/26/2013] [Indexed: 11/13/2022] Open
Abstract
Background Image-guidance maximizes the therapeutic index of brain irradiation by decreasing setup uncertainty. As dose-volume data emerge defining the tolerance of critical normal structures responsible for neuroendocrine function and neurocognition, minimizing clinical target volume (CTV) to planning target volume (PTV) expansion of targets near these structures potentially lessens long-term toxicity. Methods We reviewed the treatment records of 29 patients with brain tumors, with a total of 517 fractions analyzed. The CTV was uniformly expanded by 3 mm to create the PTV for all cases. We determined the effect of patient specific factors (prescribed medications, weight gain, tumor location) and image-guidance technique on setup uncertainty and plotted the mean +/- standard deviation for each factor. ANOVA was used to determine significance between these factors on setup uncertainty. We determined the impact of applying the initial three fraction variation as custom PTV-expansion on dose to normal structures. Results The initial 3 mm margin encompassed 88% of all measured shifts from daily imaging for all fractions. There was no difference (p = n.s.) in average setup uncertainty between CBCT or kV imaging for all patients. Vertical, lateral, longitudinal, and 3D shifts were similar (p = n.s.) between days 1, 2, and 3 imaging and later fractions. Patients prescribed sedatives experienced increased setup uncertainty (p < 0.05), while weight gain, corticosteroid administration, and anti-seizure medication did not associate with increased setup uncertainty. Patients with targets near OAR with individualized margins led to decreased OAR dose. No reductions to targets occurred with individualized PTVs. Conclusions Daily imaging allows application of individualized CTV expansion to reduce dose to OAR responsible for neurocognition, learning, and neuroendocrine function below doses shown to correlate with long-term morbidity. The demonstrated reduction in dose to OAR in this study has implications for quality of life and provides the motivation to pursue custom PTV expansion.
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Beltran C, Naik M, Merchant TE. Dosimetric effect of target expansion and setup uncertainty during radiation therapy in pediatric craniopharyngioma. Radiother Oncol 2010; 97:399-403. [PMID: 21074883 DOI: 10.1016/j.radonc.2010.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 10/14/2010] [Accepted: 10/17/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Investigate the effect of tumor change and setup uncertainties on target coverage for pediatric craniopharyngioma during RT. METHODS AND MATERIALS Fifteen pediatric patients with craniopharyngioma (mean 5.1 years) were included in this study. MRI was performed before and a median of six times during RT to monitor changes in the tumor volume. IMRT plans were created and compared to the CRT plan used for treatment. The role of adaptive therapy based on GTV changes was investigated. Dosimetric effects of interfraction and intrafraction motion were examined. RESULTS The mean of the maximal change in the GTV was 28.5% [-20.7% to 82.0%]. For the standard margin IMRT plans, the mean D(95) of the base plan on the base target was 53.6 Gy [53.1-54.1]. The mean D(95) of the base plans on the adaptive targets was 52.1 Gy [47.9-54.1]. The D(95) for the adaptive plan on the adaptive target was 53.8 Gy [53.4-54.3]. A linear regression equation of y=-0.12x , r(2)=0.70, was found for the percent change in D(95) of the PTV (y) vs. the percent change in the GTV (x). Inter and intrafraction motion did not affect the target coverage for standard and reduced margin plans. CONCLUSIONS The GTV of pediatric craniopharyngioma patients change size during therapy and adaptive planning is critical for conformal plans; therefore early and regular surveillance imaging is required.
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Affiliation(s)
- Chris Beltran
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN 38120, USA.
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Al-Mohanna H, Al-Khenaizan S. Permanent Alopecia following Cranial Irradiation in a Child. J Cutan Med Surg 2010; 14:141-3. [DOI: 10.2310/7750.2010.09014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Cranial irradiation is commonly used in childhood leukemia, with many potential cutaneous adverse effects. Radiation-induced permanent alopecia owing to scalp fibrosis is a rare but disturbing side effect. Objective and Conclusion: Here we report a Saudi boy with acute T-cell lymphoblastic leukemia who developed radiation-induced cicatricial alopecia. Topical treatment using minoxidil solution was tried but was ineffective.
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Affiliation(s)
- Hind Al-Mohanna
- From the Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sultan Al-Khenaizan
- From the Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Liu BL, Cheng JX, Zhang X, Zhang W. Controversies concerning the application of brachytherapy in central nervous system tumors. J Cancer Res Clin Oncol 2010; 136:173-85. [PMID: 19956971 DOI: 10.1007/s00432-009-0741-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2009] [Accepted: 11/19/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Brachytherapy (BRT) is defined as a therapy technique where a radioactive source is placed a short distance from or within the tumor being treated. Much expectation has been placed on its efficacy to improve the outcome for patients with central nervous system (CNS) tumors due to the initial promising results from single institution retrospective studies. However, these optimistic findings have been highly debated since the selection criteria itself is preferable to other therapeutic modalities. The fact that BRT demonstrated no significant survival advantage in two prospective studies, together with the emerging role of stereotactic convergence therapy as a promising alternative, has further decreased the enthusiasm for BRT. Despite all the negative aspects, BRT continues to be conducted for the management of CNS tumors including gliomas, meningiomas and brain metastases. MATERIAL AND METHODS As many controversies have been aroused concerning the experience and future application of BRT, this article reviews the existing heterogeneities in terms of implants choice, optimal dose rate, targeting volume, timing of BRT, patients selection, substantial efficacy, BRT in comparison with stereotactic convergence therapy techniques and BRT in combination with other treatment modalities (data were identified by Pubmed searches). RESULTS AND CONCLUSION Though it is inconvincible to argue for the routine use of BRT, BRT may provide a choice for patients with large recurrent or inoperable deep-seated tumors, especially with the Glia-site technique. Radiotherapies including BRT may hold more promise if biologic mechanisms of radiation could be better understand and biologic modifications could be added in clinical trials.
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Affiliation(s)
- Bo-Lin Liu
- Department of Neurosurgery, Xijing Institute of Clinical Neuroscience, Xijing Hospital, Fourth Military Medical University, West Changle Road, Shaanxi Province, People's Republic of China
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Abstract
INTRODUCTION The ependymomas are relatively not a common tumor. However, most clinicians agree that the radical removal of the tumor is the most important prognostic factor. MORBIDITY OF TREATMENT Tumor removal was not sufficient before the era of magnetic resonance imaging (MRI) and resulted in a considerable operative morbidity and mortality. As the microneurosurgical techniques and microsurgical anatomy become popular and the MRI provide more detailed anatomical information preoperatively, radical removal of this complex and complicated tumor can be more feasible. In childhood ependymoma, the treatment-related morbidity and mortality can be the special issues, which can modify the policy of management safe tumor removal and minimal adjuvant treatment, which are extremely important. RADIATION THERAPY Radiation treatment has been the option for disseminated disease and residual tumor. With the advancement of detailed MR anatomical information, safer and more delicate radiation becomes possible with newer radiation modalities, three-dimensional conformal radiotherapy, intensity modulating radiotherapy, and tomotherapy. PROGNOSTIC FACTORS Although many clinicians believe that the ependymomas are inheritably chemoresistant, the new targets for the treatment are under investigation or clinically tried. Also, the genetic alterations of ependymoma are developing and might be a promising target. CONCLUSION The surgical techniques and assistant modalities for tumor removal are still advancing. So, the outcome of ependymoma is still improving. Unfortunately, newer treatment modalities, such as new chemotherapeutic agent and gene modification agent, are still not promising. The history of ependymoma management is still in progress.
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Affiliation(s)
- Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, South Korea
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Wang LW, Shiau CY, Chung WY, Wu HM, Guo WY, Liu KD, Ho DMT, Wong TT, Pan DHC. Gamma Knife surgery for low-grade astrocytomas: evaluation of long-term outcome based on a 10-year experience. J Neurosurg 2009; 105 Suppl:127-32. [PMID: 18503345 DOI: 10.3171/sup.2006.105.7.127] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors report the long-term treatment results of Gamma Knife surgery (GKS) for patients with low-grade astrocytomas who underwent surgery at a single institution. METHODS A series of 21 patients (median age 20 years) with 25 intracranial low-grade astrocytomas (World Health Organization Grades I and II) were treated with GKS between 1993 and 2003. Among them, four underwent GKS as a primary treatment. Two underwent GKS as a treatment boost after radiotherapy. In the other 15 patients, GKS was performed as an adjuvant or salvage treatment for residual/recurrent tumors after the patients had undergone craniotomy. Tumor volumes ranged from 0.2 to 13.3 ml (median 2.4 ml). Prescription margin doses ranged from 8 to 18 Gy (median 14.5 Gy). Radiation volumes were 1.3 to 21.6 ml (median 3.6 ml). Patients underwent regular follow up, with neurological evaluation and magnetic resonance imaging studies obtained at 6-month intervals. One patient was lost to follow-up. The clinical follow-up time was 5 to 144 months (median 67 months). Complete tumor remission was seen in three patients. The 10-year progression-free patient survival rate after GKS was 65%. Tumor progression was found in six patients of whom five received further salvage treatment. All the tumor progression occurred within the GKS-treated volumes. Mild-to-moderate adverse radiation effects (AREs) were found in eight patients. Both of the patients who had undergone GKS as a treatment boost after radiotherapy developed AREs, but with good shrinkage of tumors. CONCLUSIONS Gamma Knife surgery provides durable long-term local tumor control with acceptable toxicity for some patients with highly selected low-grade astrocytomas.
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Affiliation(s)
- Ling-Wei Wang
- Cancer Center, Taipei Veterans General Hospital, Taiwan, Republic of China.
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Upadhyay UM, Golby AJ. Role of pre- and intraoperative imaging and neuronavigation in neurosurgery. Expert Rev Med Devices 2009; 5:65-73. [PMID: 18095898 DOI: 10.1586/17434440.5.1.65] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advances in neuroimaging acquisition, computing and image processing have enabled neurosurgeons to use radiological imaging to guide both preoperative planning and intraoperative guidance. In preoperative planning, imaging may be used to evaluate surgical risks, choose the best method of intervention and select the safest surgical approach. Neuronavigation may be useful in designing the surgical flap and alerting the surgeon of surrounding anatomy. Finally, intraoperative imaging may be used to define brain shift associated with the resection of intracranial lesions, assist in more complete lesion resection, and monitor for certain intraoperative complications. In the following review, we briefly examine the history of neuroradiology for neurosurgery, neuronavigation and intraoperative imaging and trace their advances to current systems in use. We will also highlight new experimental applications of neuroimaging that are currently being refined.
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Affiliation(s)
- Urvashi M Upadhyay
- Department of Neurosurgery, Boston Children's Hospital and Brigham and Women's Hospital, Boston, MA 02115, USA.
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16
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Taylor RE. Current developments in radiotherapy for paediatric brain tumours. Eur J Paediatr Neurol 2006; 10:167-75. [PMID: 16954052 DOI: 10.1016/j.ejpn.2006.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Accepted: 07/30/2006] [Indexed: 11/23/2022]
Abstract
This review summarises current developments in radiation oncology and how they impact on the management of children with brain tumours. Improved understanding of radiobiology has led to attempts to improve the therapeutic ratio with hyperfractionated radiotherapy. Recent advances in planning and delivery of radiotherapy, including three-dimensional conformal radiotherapy, intensity modulated radiotherapy, and proton therapy allow a more precise localisation of the maximum dose region with maximum sparing of normal brain. Increasingly interactions between drugs and radiotherapy are exploited, but it is important to evaluate toxicity of combined modality therapy. The introduction of models to predict the impact of radiotherapy dose-volume parameters on long-term neuropsychological function will hopefully lead to further benefit with respect to sparing of normal tissue morbidity.
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Affiliation(s)
- Roger E Taylor
- Clinical Oncology, South West Wales Cancer Institute, Singleton Hospital, Swansea, West Glamorgan, SA2 8QA, UK.
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Higgins PD, Gerbi BJ, Macedon M, Dusenbery KE. Fractionated stereotactic radiotherapy for pediatric patients with retinoblastoma. J Appl Clin Med Phys 2006; 7:9-17. [PMID: 17533322 PMCID: PMC5722448 DOI: 10.1120/jacmp.v7i2.2161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Revised: 01/26/2006] [Accepted: 12/31/1969] [Indexed: 12/04/2022] Open
Abstract
In this report, we discuss the application of a modified Gill‐Thomas‐Cosman (GTC) relocatable head frame to enable fractionated stereotactic radiotherapy (SRT) of infants under anesthesia. This system has been used to treat two infants, ages 12 and 18 months, for bilateral retinoblastoma on a Varian 6/100 linear accelerator. The GTC head frame was used to reproducibly position and treat the orbits of these children to between 2520 cGy and 3960 cGy in 180‐cGy fractions. A standard head and neck tray, with accompanying thermoplastic mask, was adapted to mount to the head frame to enable these treatments. We found the maximum average deviation in the repeat fixations, as compared with the initial fitting data, to be ±2mm. The overall average difference and standard deviation in measurement was 0.47±0.63mm for the first case and 0.19±0.94mm for the second case, with a combined average of 0.35±0.79mm overall from a total of 381 point measurements. The stereotactic treatment plan (Radionics®) incorporated a single isocenter for each orbit and 3 or 4 arcs per isocenter. An intercomparison has been made between this technique and a standard lateral field technique, designed using the stereotactic radiosurgery (SRS) planning system. Dose‐volume histograms and corresponding normal tissue complication probabilities (NTCP) based on pediatric bone growth inhibition have been calculated for each method for the orbital bone areas. We found that the NTCP is reduced from 95% or more in the standard treatment method to 16% or less with SRT. Use of the modified head frame provides excellent setup reproducibility, facilitates access to patients for anesthesia, and reduces the chances of a poor cosmetic result in these growing children. PACS number: 87.53.Ly
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Affiliation(s)
- Patrick D Higgins
- Department of Therapeutic Radiology-Radiation Oncology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Giller CA, Berger BD, Pistenmaa DA, Sklar F, Weprin B, Shapiro K, Winick N, Mulne AF, Delp JL, Gilio JP, Gall KP, Dicke KA, Swift D, Sacco D, Harris-Henderson K, Bowers D. Robotically guided radiosurgery for children. Pediatr Blood Cancer 2005; 45:304-10. [PMID: 15558704 DOI: 10.1002/pbc.20267] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND A robotically guided linear accelerator has recently been developed which provides frameless radiosurgery with high precision. Potential advantages for the pediatric population include the avoidance of the cognitive decline associated with whole brain radiotherapy, the ability to treat young children with thin skulls unsuitable for frame-based methods, and the possible avoidance of general anesthesia. We report our experience with this system (the "Cyberknife") in the treatment of 21 children. PROCEDURES Cyberknife radiosurgery was performed on 38 occasions for 21 patients, age ranging from 8 months to 16 years (7.0 +/- 5.1 years), with tumors considered unresectable. Three had pilocytic astrocytomas, two had anaplastic astrocytomas, three had ependymomas (two anaplastic), four had medulloblastomas, three had atypical teratoid/rhabdoid tumors, three had craniopharyngiomas, and three had other pathologies. The mean target volume was 10.7 +/- 20 cm(3), mean marginal dose was 18.8 +/- 8.1 Gy, and mean follow-up is 18 +/- 11 months. Twenty-seven (71%) of the treatments were single-shot and eight (38%) patients did not require general anesthesia. RESULTS Local control was achieved in the patients with pilocytic and anaplastic astrocytoma, three of the patients with medulloblastoma, and the three with craniopharyngioma, but not for those with ependymoma. Two of the patients with rhabdoid tumors are alive 16 and 35 months after this diagnosis. There have been no procedure related deaths or complications. CONCLUSION Cyberknife radiosurgery can be used to achieve local control for some children with CNS tumors without the need for rigid head fixation.
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Affiliation(s)
- Cole A Giller
- Baylor University Medical Center, HTPN, 8080 N. Central Expressway, Ste. 1650, Dallas, TX 75206, USA.
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Zimmermann FB, Geinitz H, Schill S, Grosu A, Schratzenstaller U, Molls M, Jeremic B. Stereotactic hypofractionated radiation therapy for stage I non-small cell lung cancer. Lung Cancer 2005; 48:107-14. [PMID: 15777977 DOI: 10.1016/j.lungcan.2004.10.015] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2004] [Revised: 10/20/2004] [Accepted: 10/27/2004] [Indexed: 02/04/2023]
Abstract
We reviewed our initial institutional experience with the use of stereotactic hypofractionated radiation therapy (SFRT) in patients with stage I non-small cell lung cancer (NSCLC). Thirty patients with inoperable stage I non-small cell lung cancer due to a severe chronic obstructive pulmonary disease (COPD) and/or chronic heart disease (Eastern Cooperative Oncology Group (ECOG) performance status of 0-2) were treated between December 2000 and October 2003 with SFRT in curative intent. Infiltration of locoregional lymph nodes and distant metastases were ruled out by computerized tomography (CT) scan of the brain, thorax, and abdomen, and by whole body FDG-positron emission tomography scan in all patients. Total RT doses ranged from 24.0 to 37.5 Gy, given in 3-5 fractions to the 60% isodose encompassing the planning target volume. Immobilization was carried out by a vacuum couch and a low-pressure foil. The clinical target volume was the tumor as it appeared in lung windowing on lung CT scan. Organ movements (caused by breathing; range, 6-22 mm) and reproducibility of patient positioning in the couch (range, 3-12 mm) were calculated by sequential CT and orthogonal films. The individual values were taken into account as a safety margin for the definition of the planning target volume (PTV). The median follow-up of living patients is 18 months (range, 6-38 months). As maximum response, there were 10 (33%) complete responses (CRs) and 14 (47%) partial responses (PRs), resulting in a total response rate of 80%. Stable disease was observed in 6 (20%) patients, while no patient experienced progressive disease. During follow-up, 2 (7%) local recurrences were observed (after 17 and 18 months, respectively). Of 5 (17%) patients who developed distant metastasis, 1 patient developed it in liver (3 months), another one in brain (6 months), and another one in the lung (36 months), while 2 patients developed it in mediastinal lymph nodes (after 8, and 11 months, respectively) only. Of 9 (30%) patients who have died, only 3 (10%) died of cancer, while 6 (20%) died of cancer-unrelated or unknown causes. Acute side effects were mild and affected 9 (33%) patients during the RT course (fatigue being the most frequent one in 6 patients). There were 22 acute events occurring in 19 (63%) patients during the first 3 months post-SFRT, the most frequent one being pneumonitis observed in 14 (46%) patients. However, there was only one (3%) grade 3 acute toxicity and no patient experienced greater than grade 3 toxicity during this study. One (3%) patient experienced rib fracture as the late event. SFRT is a feasible and safe treatment method in inoperable patients with stage I NSCLC having reduced lung capacity. Longer follow-up is necessary to get robust data on late toxicity as well as survival.
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Affiliation(s)
- Frank B Zimmermann
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University, Ismaninger Strasse 22, D-81675 Munich, Germany.
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Abstract
OBJECT The authors sought to evaluate local tumor control, complications, and progression-free survival in patients harboring low-grade gliomas who were treated with Leksell gamma knife surgery (GKS). METHODS During a 6-year period 70 patients were treated for verified low-grade gliomas (Grade I or II) by GKS. Statistical analysis was based on 68 patients; two patients were lost to follow up. The median patient age was 17 years. The median target volume was 4200 mm.3 The median prescription dose was 25 Gy. The median number of fractions was five. Ninety-five percent of patients were treated in five daily fractions. Partial or complete tumor regression was achieved in 83% of patients with a median time to response of 18 months. There was moderate acute or late toxicity in not more than 5% of patients. In this series the progression-free survival was 92% at 3 years and 88% at 5 years. CONCLUSIONS Relatively high local tumor control with minimal complications was achieved.
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Affiliation(s)
- Gabriela Simonová
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
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Krengli M, Hug EB, Adams JA, Smith AR, Tarbell NJ, Munzenrider JE. Proton radiation therapy for retinoblastoma: Comparison of various intraocular tumor locations and beam arrangements. Int J Radiat Oncol Biol Phys 2005; 61:583-93. [PMID: 15667981 DOI: 10.1016/j.ijrobp.2004.06.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Revised: 05/27/2004] [Accepted: 06/03/2004] [Indexed: 11/25/2022]
Abstract
PURPOSE To study the optimization of proton beam arrangements for various intraocular tumor locations; and to correlate isodose distributions with various target and nontarget structures. METHODS AND MATERIALS We considered posterior-central, nasal, and temporal tumor locations, with straight, intrarotated, or extrarotated eye positions. Doses of 46 cobalt grey equivalent (CGE) to gross tumor volume (GTV) and 40 CGE to clinical target volume (CTV) (2 CGE per fraction) were assumed. Using three-dimensional planning, we compared isodose distributions for lateral, anterolateral oblique, and anteromedial oblique beams and dose-volume histograms of CTVs, GTVs, lens, lacrimal gland, bony orbit, and soft tissues. RESULTS All beam arrangements fully covered GTVs and CTVs with optimal lens sparing. Only 15% of orbital bone received doses > or =20 CGE with a lateral beam, with 20-26 CGE delivered to two of three growth centers. The anterolateral oblique approach with an intrarotated eye resulted in additional reduction of bony volume and exposure of only one growth center. No appreciable dose was delivered to the contralateral eye, brain tissue, or pituitary gland. CONCLUSIONS Proton therapy achieved homogeneous target coverage with true lens sparing. Doses to orbit structures, including bony growth centers, were minimized with different beam arrangements and eye positions. Proton therapy could reduce the risks of second malignancy and cosmetic and functional sequelae.
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Affiliation(s)
- Marco Krengli
- Department of Radiotherapy, University of Piemonte Orientale, Novara, Italy
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Abstract
Object. The authors sought to evaluate local tumor control, complications, and progression-free survival in patients harboring low-grade gliomas who were treated with Leksell gamma knife surgery (GKS).
Methods. During a 6-year period 70 patients were treated for verified low-grade gliomas (Grade I or II) by GKS. Statistical analysis was based on 68 patients; two patients were lost to follow up. The median patient age was 17 years. The median target volume was 4200 mm.3 The median prescription dose was 25 Gy. The median number of fractions was five. Ninety-five percent of patients were treated in five daily fractions.
Partial or complete tumor regression was achieved in 83% of patients with a median time to response of 18 months. There was moderate acute or late toxicity in not more than 5% of patients. In this series the progression-free survival was 92% at 3 years and 88% at 5 years.
Conclusions. Relatively high local tumor control with minimal complications was achieved.
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Abstract
BACKGROUND Craniopharyngiomas are the most common intracranial tumor of extraneural origin in childhood. REVIEW SUMMARY In this review, we discuss the presentation, diagnosis, and treatment of craniopharyngioma. As the survival prognosis of patients with craniopharyngioma is quite optimistic, long-term side effects of both the tumor and its treatment are now better appreciated. Aside from well-recognized hormonal deficiencies and visual deficits related to tumor location, patients are now acknowledged to experience pathologic obesity and deficits of higher cortical function, memory, and behavior. The combination of these deficits can have profoundly detrimental effects on quality of life. CONCLUSIONS Careful attention to issues related to hormonal balance, visual field defects, cognitive function, and mood disorders is essential to optimize long-term outcome of patients with craniopharyngioma.
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Affiliation(s)
- Nicole J Ullrich
- Division of Neuroscience, Department of Neurology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Radiation therapy plays a central role in the management of many childhood brain tumors. By combining advances in brain tumor imaging with technology to plan and deliver radiation therapy, pediatric brain tumors can be treated with conformal radiation therapy. Through conformal radiation therapy, the radiation dose is targeted to the tumor, which can minimize the dose to normal brain structures. Therefore, by limiting the radiation dose to normal brain tissues, conformal radiation therapy offers the possibility of limiting the long-term side effects of brain irradiation.In this review, we describe different approaches to conformal radiation therapy for pediatric central nervous system tumors including: A) three-dimensional conformal radiation therapy; B) stereotactic radiation therapy with arc photons; C) intensity-modulated radiation therapy; and D) proton beam radiation therapy. We discuss the merits and limitations of these techniques and describe clinical scenarios in which conformal radiation therapy offers advantages over conventional radiation therapy for treating pediatric brain tumors.
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Affiliation(s)
- David G Kirsch
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Lawenda BD, Gagne HM, Gierga DP, Niemierko A, Wong WM, Tarbell NJ, Chen GTY, Hochberg FH, Loeffler JS. Permanent alopecia after cranial irradiation: Dose–response relationship. Int J Radiat Oncol Biol Phys 2004; 60:879-87. [PMID: 15465206 DOI: 10.1016/j.ijrobp.2004.04.031] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2003] [Revised: 01/26/2004] [Accepted: 04/12/2004] [Indexed: 11/29/2022]
Abstract
PURPOSE To develop a dose-response relationship for the occurrence of permanent alopecia after cranial irradiation and to analyze potential confounding variables that may contribute to this unwanted and often unavoidable complication of treatment. METHODS AND MATERIALS Twenty-six patients were enrolled in this study. Three reviewers independently assessed 61 scalp regions and assigned a score for the degree of alopecia in each region using a 4-point scale. Patient and treatment data were collected using a patient questionnaire and outpatient medical chart review. The hair follicle dose was calculated for each scalp region and correlated with the alopecia score for that region. A dose-response relationship was established using the data from these correlations. RESULTS Permanent alopecia correlated significantly with the follicle dose only (p < 0.001). A personal history of alopecia and the use of chemotherapy correlated with permanent alopecia with borderline statistical significance (p = 0.059 and p = 0.068, respectively). Patient age, family history of baldness, gender, tobacco use, diabetes, and beam energy did not correlate with alopecia. CONCLUSION We report the first human dose-response relationship describing the effect of the follicle dose on the subsequent development of permanent scalp alopecia after cranial irradiation. This information will assist the radiation oncologist, physicist, and dosimetrist in designing a treatment plan that might minimize the risk of this untoward side effect of cranial irradiation.
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Affiliation(s)
- Brian D Lawenda
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, 100 Blossom Street, Boston, MA 02114, USA
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Giller CA, Berger BD, Gilio JP, Delp JL, Gall KP, Weprin B, Bowers D. Feasibility of Radiosurgery for Malignant Brain Tumors in Infants by Use of Image-guided Robotic Radiosurgery: Preliminary Report. Neurosurgery 2004; 55:916-24; discussion 924-5. [PMID: 15458600 DOI: 10.1227/01.neu.0000137332.03970.57] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2003] [Accepted: 05/24/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
The benefits of radiation therapy are generally denied to infants with malignant brain tumors because of the risk of devastating cognitive decline. Efforts to limit this morbidity with radiosurgical techniques have not been feasible for infants because of the dual requirements of rigid head fixation and high precision. We report the radiosurgical treatment of five infants by use of a robotically controlled system without rigid head fixation.
METHODS:
Five infants with malignant brain tumors received radiosurgical treatment with a robotically driven linear accelerator. Immobilization was aided by general anesthesia, form-fitting head supports, face masks, and body molds. The average marginal dose was 17 ± 2 Gy, and the average treatment volume was 18 ± 22 ml.
RESULTS:
X-rays obtained during treatment revealed acceptable agreement with preoperative computed tomographic scans in all patients. In one patient, the lesion did not progress, but a distant recurrence occurred 15 months after radiosurgery and also was treated with radiosurgery. In another patient, tumor in the treated region did not progress, but recurrence elsewhere led to death 7 months after treatment. Tumor enlargement occurred in Patient 3 at 3 months posttreatment, leading to death 2 months later. Tumor size was smaller in the remaining two patients at 9 and 11 months after treatment. There has been no toxicity attributed to treatment.
CONCLUSION:
Radiosurgery with minimal toxicity can be delivered to infants by use of a robotically controlled system that does not require rigid fixation. A formal dose-escalation trial is under way to address dose and toxicity for infants more thoroughly.
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Affiliation(s)
- Cole A Giller
- Department of Neurological Surgery, Baylor University Medical Center, Dallas, Texas 75206, USA.
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Selch MT, Ahn E, Laskari A, Lee SP, Agazaryan N, Solberg TD, Cabatan-Awang C, Frighetto L, Desalles AAF. Stereotactic radiotherapy for treatment of cavernous sinus meningiomas. Int J Radiat Oncol Biol Phys 2004; 59:101-11. [PMID: 15093905 DOI: 10.1016/j.ijrobp.2003.09.003] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Revised: 08/20/2003] [Accepted: 09/03/2003] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the safety and efficacy of stereotactic radiotherapy (SRT) using a linear accelerator equipped with a micromultileaf collimator for cavernous sinus meningiomas. METHODS AND MATERIALS Forty-five patients with benign cavernous sinus meningiomas were treated with SRT between November 1997 and April 2002. Sixteen patients received definitive treatment on the basis of imaging characteristics of the cavernous sinus tumor. Twenty-nine patients received SRT either as immediate adjuvant treatment after incomplete resection or at documented recurrence. Treatment planning in all patients included CT-MRI image fusion and beam shaping using a micromultileaf collimator. The primary tumor volume varied from 1.41 to 65.66 cm(3) (median, 14.5 cm(3)). The tumor diameter varied from 1.4 to 7.4 cm (median, 3.8 cm). Tumor compressed the optic chiasm or optic nerve in 30 patients. All tumors were treated with a single isocenter plus a margin of normal parenchyma varying from 1 to 5 mm (median, 2.5 mm). The prescribed dose varied from 4250 to 5400 cGy (median, 5040 cGy). The prescription isodose varied from 87% to 95% (median, 90%). The maximal tumor dose varied from 5000 to 6000 cGy (median, 5600 cGy). The follow-up varied from 12 to 53 months (median, 36 months). RESULTS The actuarial 3-year overall and progression-free survival rate was 100% and 97.4%, respectively. One patient (2%) developed local relapsed at 18 months. A partial imaging response occurred in 18% of patients, and the tumor was stable in the remaining 80%. Preexisting neurologic complaints improved in 20% of patients and were stable in the remainder. No patient, tumor, or treatment factors were found to be predictive of imaging or clinical response. Transient acute morbidities included headache responsive to nonnarcotic analgesics in 4 patients, fatigue in 3 patients, and retroorbital pain in 1 patient. No treatment-induced peritumoral edema, cranial neuropathy, endocrine dysfunction, cognitive decline, or second malignancy occurred. One patient had an ipsilateral cerebrovascular accident 6 months after SRT. CONCLUSION Stereotactic radiotherapy is both safe and effective for patients with cavernous sinus meningiomas. Field shaping using a micromultileaf collimator allows conformal and homogeneous radiation of cavernous sinus meningiomas that may not be amenable to single-fraction stereotactic radiosurgery because of tumor size or location. Additional clinical experience is necessary to determine the position of SRT among the available innovative fractionated RT options for challenging skull base meningiomas.
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Affiliation(s)
- Michael T Selch
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA 90045-6951, USA.
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28
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Jaywant SM, Osei EK, Ladak S. Stereotactic radiotherapy in the treatment of ocular melanoma: a noninvasive eye fixation aid and tracking system. J Appl Clin Med Phys 2003; 4:156-61. [PMID: 12777151 PMCID: PMC5724480 DOI: 10.1120/jacmp.v4i2.2531] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ocular melanoma is frequently treated using brachytherapy implants (such as 125I and 60Co plaques or 184Ta wire), surgery, or external beam radiotherapy using small 60Co beams, high energy x-rays, or proton therapy. The last technique, though very expensive, provides improved dose distributions and dose localizations in the treatment of tumours adjacent to critical normal tissues. The technique of fractionated stereotactic radiotherapy is now being used at an increasingly large number of centers in the treatment of lesions in the brain, and the head and neck. This article describes the successful extension of the stereotactic technique to the treatment of ocular melanoma: an eye fixation aid is attached to a noninvasive, relocatable Gill-Thomas-Cosman head frame together with a simple eye-movement tracking system.
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Affiliation(s)
- S. M. Jaywant
- Department of Radiation PhysicsPrincess Margaret Hospital610 University AvenueTorontoOntarioM5G 2M9Canada
| | - E. K. Osei
- Department of Radiation PhysicsPrincess Margaret Hospital610 University AvenueTorontoOntarioM5G 2M9Canada
| | - S. Ladak
- Department of Radiation TherapyPrincess Margaret Hospital610 University AvenueTorontoOntarioM5G 2M9Canada
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Varlotto JM, Flickinger JC, Kondziolka D, Lunsford LD, Deutsch M. External beam irradiation of craniopharyngiomas: long-term analysis of tumor control and morbidity. Int J Radiat Oncol Biol Phys 2002; 54:492-9. [PMID: 12243827 DOI: 10.1016/s0360-3016(02)02965-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To delineate the long-term control and morbidity with external beam radiotherapy (EBRT) of craniopharyngiomas. METHODS AND MATERIALS Between 1971 and 1992, 24 craniopharyngioma patients underwent EBRT at the University of Pittsburgh. Most (19 of 24) were treated within 1-3 months after subtotal resection. The other prior surgical procedures were biopsy (n = 2) and gross total resection (n = 1); 2 patients did not undergo any surgical procedure. The median follow-up was 12.1 years. The median patient age was 29 years (range 5-69). The total radiation doses varied from 36 to 70 Gy (median 59.75). The normalized total dose (NTD, biologically equivalent dose given in 2 Gy/fraction [alpha/beta ratio = 2]) varied from 28 to 83 Gy (median 55.35). RESULTS The actuarial survival rate at 10 and 20 years was 100% and 92.3%, respectively. The actuarial local control rate at 10 and 20 years was 89.1% and 54.0%, respectively. No local failures occurred with doses >or=60 Gy (n = 12) or NTDs >or=55 Gy. The complication-free survival rate at 10 and 20 years was 80.1% and 72.1%, respectively. No complications were noted with an NTD of <or=55 Gy. The actuarial survival free from any adverse outcome (recurrence or complication) was 70.1% and 31.8% at 10 and 20 years, respectively. The adverse outcome-free survival appeared optimized (at 73%) with an NTD of 55-63 Gy. Multivariate analysis found that tumor control correlated significantly with the total dose (p = 0.02), treatment complications with NTD (p = 0.008), and adverse outcome with hypopituitarism on presentation (p = 0.03). CONCLUSION We recommend treating craniopharyngioma with 1.6-1.7-Gy dose fractions to 60 Gy to optimize outcome from EBRT.
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Affiliation(s)
- John M Varlotto
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Center for Image-Guided Neurosurgery, and Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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30
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Szumacher E, Schwartz ML, Tsao M, Jaywant S, Franssen E, Wong CS, Ramaseshan R, Lightstone AW, Michaels H, Hayter C, Laperriere NJ. Fractionated stereotactic radiotherapy for the treatment of vestibular schwannomas: combined experience of the Toronto-Sunnybrook Regional Cancer Centre and the Princess Margaret Hospital. Int J Radiat Oncol Biol Phys 2002; 53:987-91. [PMID: 12095567 DOI: 10.1016/s0360-3016(02)02779-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the efficacy and toxicity of fractionated stereotactic radiotherapy (FSRT) for vestibular schwannomas in patients treated at two university-affiliated hospitals. METHODS AND MATERIALS Thirty-nine patients were treated between April 1996 and September 2000. The median age was 56 years (range: 29-80), and median maximal tumor diameter was 20 mm (range: 9-40). A total of 11 patients had fifth and/or seventh cranial nerve dysfunction before irradiation; 2 patients had only facial weakness, 5 patients had only facial numbness, and 4 patients had both facial weakness and numbness. Thirty-three patients were treated with primary FSRT, and 6 patients were treated for recurrent or persistent disease after previous surgery. All patients were treated with 6-MV photons using a stereotactic system with a relocatable frame. The 39 patients received 50 Gy in 25 fractions over 5 weeks. Median follow-up was 21.8 months (range: 4.4-49.6). RESULTS Local control was achieved in 37 patients (95%). Two patients experienced deterioration of their symptoms at 3 and 20 months as a result of clinical progression in one case and tumor progression in the other and underwent surgery post FSRT. A total of 19/28 (67.9%) patients preserved serviceable hearing after FSRT. Deterioration of the facial and trigeminal nerves was observed in only 2 patients who were treated with surgery post FSRT. CONCLUSION FSRT provided excellent tumor control with minimal morbidity and good hearing preservation in this cohort of patients. Longer follow-up is required to confirm long-term control rates.
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Affiliation(s)
- Ewa Szumacher
- Department of Radiation Oncology, Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada.
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31
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Selch MT, DeSalles AAF, Wade M, Lee SP, Solberg TD, Wallace RE, Ford JM, Rubino G, Cabatan-Awang C, Withers HR. Initial clinical results of stereotactic radiotherapy for the treatment of craniopharyngiomas. Technol Cancer Res Treat 2002; 1:51-9. [PMID: 12614177 DOI: 10.1177/153303460200100107] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The efficacy and toxicity of stereotactic radiotherapy (SRT) for the treatment of craniopharyngioma has been retrospectively evaluated in 16 patients. The median tumor diameter was 2.8 cm (range 1.5-6.1) and the median tumor volume was 7.7 cc (range 0.7-62.8). SRT was delivered to a single isocenter using a dedicated 6 MV linear accelerator to patients immobilized with a relocatable stereotactic head frame. The three-year actuarial overall survival was 93% and the rate of survival free of any imaging evidence of progressive disease was 75%. The three-year actuarial survival rates free of solid tumor growth or cyst enlargement were 94% and 81% respectively. Our results suggest that SRT is a safe and effective treatment approach for patients with craniopharyngioma. Long-term follow-up is required to determine whether the normal tissue-sparing inherent with SRT results in reduction of the neurocognitive effects of conventional radiotherapy for craniopharyngioma. SRT can be delivered to craniopharyngioma that may be difficult to treat with stereotactic radiosurgery due to proximity of the optic chiasm. Further clinical experience is necessary to determine the clinical utility of beam shaping in the setting of SRT.
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Affiliation(s)
- Michael T Selch
- Department of Radiation Oncology, School of Medicine, University of California, Los Angeles CA 90095, USA.
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32
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Merchant TE, Zhu Y, Thompson SJ, Sontag MR, Heideman RL, Kun LE. Preliminary results from a Phase II trail of conformal radiation therapy for pediatric patients with localised low-grade astrocytoma and ependymoma. Int J Radiat Oncol Biol Phys 2002; 52:325-32. [PMID: 11872277 DOI: 10.1016/s0360-3016(01)01807-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To estimate the local control and patterns of failure for pediatric patients with low-grade astroglial tumors (LGA) and ependymoma (EP) treated with three-dimensional conformal radiation therapy (CRT) using an anatomically defined clinical target volume (CTV). METHODS AND MATERIALS From an ongoing, prospective Phase II trial initiated in July 1997, 102 pediatric patients with LGA (n = 38) and EP (n = 64) have been treated with CRT using an anatomically defined CTV extending 1.0 cm beyond the gross tumor volume and a 0.5-cm margin (planning target volume) extending outside of the CTV. The prescribed dose was 54 Gy (LGA) and 59.4 Gy (EP). RESULTS Patients with EP have been followed for a median of 17 months (range 3--43 months), and six failures have occurred. Patients with LGA have been followed for a median of 17 months (3--44 months), and four failures have occurred. Three-dimensional magnetic resonance (MR) studies performed to document treatment failure were registered with the MR and computed tomography (CT) data used in the treatment planning process. Failure occurred within the CTV for 5 patients with EP, including 3 with concurrent subarachnoid dissemination. One patient with EP developed metastatic disease with no evidence of local failure. Three patients with LGA failed within the CTV and one failed immediately outside of the CTV. CONCLUSIONS Treatment of an anatomically defined CTV, encompassing 1.0 cm of non-involved brain beyond the margin of resection or neuroimaging-defined tumor, appears to be safe for pediatric patients with LGA and EP based on these preliminary data. Normal tissue sparing through the use of advanced radiation therapy treatment planning and delivery techniques should be beneficial to pediatric patients if the rate and patterns of failure are similar to conventional techniques and toxicity reduction can be objectively documented.
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Affiliation(s)
- Thomas E Merchant
- Department of Radiation Oncology St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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33
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Zissiadis Y, Dutton S, Kieran M, Goumnerova L, Scott RM, Kooy HM, Tarbell NJ. Stereotactic radiotherapy for pediatric intracranial germ cell tumors. Int J Radiat Oncol Biol Phys 2001; 51:108-12. [PMID: 11516859 DOI: 10.1016/s0360-3016(01)01569-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Intracranial germ cell tumors are rare, radiosensitive tumors seen most commonly in the second and third decades of life. Radiotherapy alone has been the primary treatment modality for germinomas, and is used with chemotherapy for nongerminomatous tumors. Stereotactic radiotherapy techniques minimize the volume of surrounding normal tissue irradiated and, hence, the late radiation morbidity. This study reports our experience with stereotactic radiotherapy in this group of tumors. METHODS AND MATERIALS Between December 1992 and December 1998, 18 patients with intracranial germ cell tumors were treated with stereotactic radiotherapy. A total of 23 histologically proven tumors were treated. Thirteen patients had a histologic diagnosis of germinoma, and 5 patients had germinoma with nongerminomatous elements. Of those patients with a histologic diagnosis of germinoma, 5 had multiple midline tumors. The median age of the patients was 12.9 years (range, 5.6-17.5 years). RESULTS A boost using stereotactic radiotherapy was delivered to 19 tumors following whole-brain radiation in 8 cases and craniospinal radiation in 11 cases. Three tumors were treated with stereotactic radiotherapy to the tumor volume alone following chemotherapy, and 1 tumor received a boost using stereotactic radiosurgery following craniospinal radiation. A median dose of 2520 cGy (range, 1500-3600) cGy was given to the whole brain, and a median dose of 2160 (range, 2100-2600) cGy was given to the spinal field. The median boost dose to the tumor was 2600 (range, 2160-3600) cGy, given by stereotactic radiotherapy delivered to the 95% isodose line. At a median follow-up time of 40 (range, 12-73) months, no local or marginal recurrences were reported in patients with germinoma. Two patients with nongerminomatous tumors have relapsed. One had elevation of tumor markers only at 37 months following treatment, and the other had persistent disease following chemotherapy and radiation therapy. Eight patients documented pituitary-hypothalamic dysfunction; in 7 (87.5%) of these patients, the dysfunction was present before commencing radiotherapy. Four patients (22%) developed newly diagnosed diabetes insipidus following surgery. Three patients (17%) received antidepressant medication at follow-up. CONCLUSION Our series shows that stereotactic radiotherapy is achievable and well tolerated in this group of patients. Longer follow-up is required to fully assess the impact on long-term toxicity. Psychologic assessment of mood and affect should be performed as part of routine follow-up in this group of adolescent children.
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Affiliation(s)
- Y Zissiadis
- Department of Radiation Oncology, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Watson GA, Kadota RP, Wisoff JH. Multidisciplinary management of pediatric low-grade gliomas. Semin Radiat Oncol 2001; 11:152-62. [PMID: 11285553 DOI: 10.1053/srao.2001.21421] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Low-grade gliomas comprise a heterogeneous group of tumors accounting for 30% to 40% of all primary central nervous system (CNS) neoplasms in the pediatric population. Management of these patients has evolved significantly over the past 2 decades, the present emphasis being on surgery. Adjuvant therapies, such as radiation and/or chemotherapy are generally withheld until symptomatic or radiographic progression is evident. The goal of surgery is gross total resection, while preserving maximal neurologic function. The goal of radiation and chemotherapy is to provide symptom and tumor control with minimal acute and late toxicities. Chemotherapy has the additional goal of deferring radiation to allow maximal development and maturation of the child's CNS. The incorporation of these 3 modalities into the overall care of the pediatric low-grade glioma patient involves the multidisciplinary input of the neurosurgeon, radiation oncologist, and pediatric neuro-oncologist both at time of diagnosis and throughout the course of their disease.
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Affiliation(s)
- G A Watson
- Department of Radiation Oncology, Primary Children's Medical Center, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
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35
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Kalapurakal JA, Ilahi Z, Kepka AG, Bista T, Goldman S, Tomita T, Marymont MH. Repositioning accuracy with the Laitinen frame for fractionated stereotactic radiation therapy in adult and pediatric brain tumors: preliminary report. Radiology 2001; 218:157-61. [PMID: 11152795 DOI: 10.1148/radiology.218.1.r01ja23157] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the repositioning accuracy, patient tolerance, and clinical efficacy of stereotactic radiation therapy for brain tumors in children and adults performed with the Laitinen stereotactic localizer and head holder. MATERIALS AND METHODS In this retrospective analysis, stereotactic frame tolerance was assessed by recording patient discomfort or pain in the ear and nose during each treatment in 34 patients, including 21 children and 13 adults with 37 lesions treated with fractionated stereotactic radiation therapy. Radiation doses ranged from 10-60 Gy at 1.0-4.0 Gy per fraction. Repositioning accuracy was assessed by comparing portal radiographs with setup fields on computed tomographic (CT) scout images. Clinical efficacy was assessed by analyzing posttreatment CT and magnetic resonance images. RESULTS The stereotactic localizer was well tolerated. The mean isocenter shifts observed after studying 305 portal radiographs were x-coordinate shift of 1.0 mm +/- 0.7 (SD), y-coordinate shift of 0.8 mm +/- 0.8, and z-coordinate shift of 1.7 mm +/- 1.0. At a median follow-up of 16 months, local control was achieved in 18 of 22 primary and in one of eight of recurrent tumors. CONCLUSION The Laitinen stereotactic localizer is well tolerated with accurate reproducibility during stereotactic radiation therapy. Preliminary local control rates are consistent with those in other reports.
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Affiliation(s)
- J A Kalapurakal
- Divisions of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, L-178, Chicago, IL 60611, USA
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36
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Uematsu M, Shioda A, Suda A, Tahara K, Kojima T, Hama Y, Kono M, Wong JR, Fukui T, Kusano S. Intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy for lung or liver cancers with a fusion of CT and linear accelerator (FOCAL) unit. Int J Radiat Oncol Biol Phys 2000; 48:443-8. [PMID: 10974460 DOI: 10.1016/s0360-3016(00)00619-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy (SRT) for lung or liver cancers, we checked repeated CT scanning, with a fusion of CT and linear accelerator (FOCAL) unit. METHODS AND MATERIALS The FOCAL unit is a combination of a linear accelerator (Linac), CT scanner, X-ray simulator (X-S), and carbon table, and is designed to achieve CT-guided SRT with daily CT positioning followed by immediate irradiation while patients keep reduced shallow respirations. To evaluate intrafractional tumor position stability, 50 lung or liver lesions in 20 patients were checked by repeated CT scanning just before and after irradiation, and the obtained images were compared. RESULTS There was no case with the intrafractional error judged to be greater than 10 mm. In 68% of cases, the intrafractional positioning errors were negligible (0-5 mm). CONCLUSIONS Using the FOCAL unit, SRT for lung or liver cancers could be performed with intrafractional positioning errors not greater than 10 mm.
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Affiliation(s)
- M Uematsu
- Division of Radiation Oncology, National Defense Medical College, Tokorozawa, Saitama, Japan
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38
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Suh JH, Barnett GH, Sohn JW, Kupelian PA, Cohen BH. Results of linear accelerator-based stereotactic radiosurgery for recurrent and newly diagnosed acoustic neuromas. Int J Cancer 2000; 90:145-51. [PMID: 10900426 DOI: 10.1002/1097-0215(20000620)90:3<145::aid-ijc4>3.0.co;2-v] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Stereotactic radiosurgery (SRS) is used to treat acoustic neuromas, but additional information is needed to firmly establish its safety and efficacy. We review our experience over 7 years treating 29 consecutive patients with a modified linear accelerator (linac) SRS system. Between August 1989 and October 1995, 29 patients with a median age of 67 years (range 26 to 83) underwent linac SRS treatment. Twenty-five patients had unilateral acoustic neuromas, and four patients with neurofibromatosis type II had bilateral vestibular schwannoma. Eligibility criteria for SRS were recurrent tumors (n = 9), age >65 (n = 16), or patient preference (n = 6). Follow-up magnetic resonance imaging scans were performed on all patients. The most common presenting symptoms were hearing impairment (18 patients) and gait difficulties (17 patients). Ten patients were deaf in the affected ear prior to treatment. Doses to the periphery of the tumor ranged from 800 to 2,400 cGy (median 1, 600 cGy) prescribed to the 50% to 80% isodose line (median 80%). After a median radiographic follow-up of 49 months (range 4 to 110 months), 11 tumors were smaller, 17 were stable, and one had evidence of progression (at 41 months). The 5-year local disease control rate (Kaplan-Meier estimate) was 94%. Acute complications were minimal, with only two patients experiencing nausea and vomiting after the procedure. Long-term complications included new or progressive trigeminal and facial nerve deficits with estimated 5-year incidences of 15% and 32%, respectively. Subjective hearing reduction or loss occurred in 14 (74%) of the 19 patients who had useful hearing prior to treatment. Five patients died from unrelated causes. These results suggest that linac SRS provides excellent short-term tumor control rates. Since there was a high risk of cranial nerve neuropathy, we do not recommend using only computed tomography-based planning and high prescription doses. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 145-151 (2000).
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Affiliation(s)
- J H Suh
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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39
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Uematsu M, Sonderegger M, Shioda A, Tahara K, Fukui T, Hama Y, Kojima T, Wong JR, Kusano S. Daily positioning accuracy of frameless stereotactic radiation therapy with a fusion of computed tomography and linear accelerator (focal) unit: evaluation of z-axis with a z-marker. Radiother Oncol 1999; 50:337-9. [PMID: 10392820 DOI: 10.1016/s0167-8140(99)00037-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To evaluate quantitative positioning errors of frameless stereotactic radiation therapy with a fusion of computed tomography (CT) and linear accelerator unit, Z-type CT markers were attached to patients, and CT images were obtained before and after daily treatment. In 40 verification tests, geometrical errors were never more than 1 mm.
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Affiliation(s)
- M Uematsu
- Division of Radiation Oncology, National Defense Medical College, Tokorozawa, Saitama, Japan
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Werner-Wasik M, Rudoler S, Preston PE, Hauck WW, Downes BM, Leeper D, Andrews D, Corn BW, Curran WJ. Immediate side effects of stereotactic radiotherapy and radiosurgery. Int J Radiat Oncol Biol Phys 1999; 43:299-304. [PMID: 10030253 DOI: 10.1016/s0360-3016(98)00410-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE Despite increased utilization of fractionated stereotactic radiation therapy (SRT) or stereotactic radiosurgery (SRS), the incidence and nature of immediate side effects (ISE) associated with these treatment techniques are not well defined. We report immediate side effects from a series of 78 patients. MATERIALS AND METHODS Intracranial lesions in 78 adult patients were treated with SRT or SRS, using a dedicated linear accelerator. Those lesions included 13 gliomas, 2 ependymomas, 19 metastatic tumors, 15 meningiomas, 12 acoustic neuromas, 4 pituitary adenomas, 1 optic neuroma, 1 chondrosarcoma, and 11 arteriovenous malformations (AVM). SRT was used in 51 and SRS in 27 patients. Mean target volume was 9.0 cc. Eleven patients received prior external-beam radiation therapy within 2 months before SRT/SRS. Any side effects occurring during and up to 2 weeks after the course of radiation were defined as ISE and were graded as mild, moderate, or severe. The incidence of ISE and the significance of their association with several treatment and pretreatment variables were analyzed. RESULTS Overall, 28 (35%) of 78 patients experienced one or more ISE. Most of the ISE (87%) were mild, and consisted of nausea (in 5), dizziness/vertigo (in 5), seizures (in 6), and new persistent headaches (in 17). Two episodes of worsening neurological deficit and 2 of orbital pain were graded as moderate. Two patients experienced severe ISE, requiring hospitalization (1 seizure and 1 worsening neurological deficit). ISE in 6 cases prompted computerized tomography of the brain, which revealed increased perilesional edema in 3 cases. The incidence of ISE by diagnosis was as follows: 46% (6 of 13) for gliomas, 50% (6 of 12) for acoustic neuromas, 36% (4 of 11) for AVM, 33% (5 of 15) for meningiomas, and 21% (4 of 19) for metastases. A higher incidence of dizziness/vertigo (4 of 12 = 33%) was seen among acoustic neuroma patients than among other patients (p< 0.01). There was no significant association of dizziness/vertigo with either a higher average and maximum brainstem dose (p = 0.74 and 0.09, respectively) or with 2-Gy equivalents of the average and maximum brainstem doses (p = 0.28 and 0.09, respectively). Higher RT dose to the margin and higher maximum RT dose were associated with a higher incidence of ISE (p = 0.05 and 0.01, respectively). However, when RT dose to the margin was converted to a 2-Gy dose-equivalent, it lost its significance as predictor of ISE (p = 0.51). Recent conventional external-beam radiation therapy, target volume, number of isocenters, collimator size, dose inhomogeneity, prescription isodose, pretreatment edema, dose of prior radiation, fraction size (2.0-7.0 Gy with SRT and 13.0-21.0 Gy with SRS), fractionation schedule, and dose to brainstem were not significantly associated with ISE. ISE occurred in 26% (8) of 31 patients taking corticosteroids prior to SRT/SRS and in 20 (42%) of 47 patients not taking them (p = 0.15). CONCLUSION ISE occur in one third of patients treated with SRT and SRS and are usually mild or moderate and self-limited. Dizziness/vertigo are common and unique for patients with acoustic neuromas and are not associated with higher brainstem doses. We are unable to detect a relationship between ISE and higher margin or maximum RT doses. No specific conclusion can be drawn with regard to the effect of corticosteroids, used prior to SRS/SRT, on the occurrence of ISE.
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Affiliation(s)
- M Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
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Shafron DH, Friedman WA, Buatti JM, Bova FJ, Mendenhall WM. Linac radiosurgery for benign meningiomas. Int J Radiat Oncol Biol Phys 1999; 43:321-7. [PMID: 10030256 DOI: 10.1016/s0360-3016(98)00391-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To review outcomes for patients treated with linac radiosurgery for benign meningiomas. METHODS AND MATERIALS Between January 1989 and July 1997, 70 patients with 76 meningiomas were treated with LINAC-based radiosurgery. In 38 patients, radiosurgery was the initial treatment. In 32 patients, radiosurgery followed surgery or conventional radiotherapy. The average treatment volume was 10.0 cm3 (range, 0.6 to 28.6 cm3). The mean peripheral dose was 12.7 Gy (range, 10 to 20 Gy). The mean clinical follow-up period was 23 months. No patient was lost to follow-up. RESULTS No lesions enlarged during the follow-up period; of 48 lesions in patients who had follow-up for at least one year and hence had follow-up imaging, 27 tumors remained unchanged and 21 tumors were reduced in size. Two patients experienced transient radiation-induced neurological deficits. One was treated with surgical excision of the tumor; the other responded to prolonged steroid therapy. Both patients, treated early in our experience, received doses higher than we would currently recommend. CONCLUSIONS Early results suggest that stereotactic radiosurgery is an effective treatment for meningiomas. Long-term follow-up will be necessary to fully evaluate its efficacy.
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Affiliation(s)
- D H Shafron
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, USA
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Mitsumori M, Shrieve DC, Alexander E, Kaiser UB, Richardson GE, Black PM, Loeffler JS. Initial clinical results of LINAC-based stereotactic radiosurgery and stereotactic radiotherapy for pituitary adenomas. Int J Radiat Oncol Biol Phys 1998; 42:573-80. [PMID: 9806517 DOI: 10.1016/s0360-3016(98)00256-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To retrospectively evaluate the initial clinical results of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) for pituitary adenomas with regard to tumor and hormonal control and adverse effects of the treatment. SUBJECTS AND METHODS Forty-eight patients with pituitary adenoma who underwent SRS or SRT between September 1989 and September 1995 were analyzed. Of these, 18 received SRS and 30 received SRT. The median tumor volumes were 1.9 cm3 for SRS and 5.7 cm3 for SRT. Eleven of the SRS and 18 of the SRT patients were hormonally active at the time of the initial diagnosis. Four of the SRS and none of the SRT patients had a history of prior radiation therapy. Both SRS and SRT were performed using a dedicated stereotactic 6-MV linear accelerator (LINAC). The dose and normalization used for the SRS varied from 1000 cGy at 85% of the isodose line to 1500 cGy at 65% of the isodose line. For SRT patients, a total dose of 4500 cGy at 90% or 95% of the isodose line was delivered in 25 fractions of 180 cGy daily doses. RESULTS Disease control-The three year tumor control rate was 91.1% (100% for SRS and 85.3% for SRT). Normalization of the hormonal abnormality was achieved in 47% of the 48 patients (33% for SRS and 54% for SRT). The average time required for normalization was 8.5 months for SRS and 18 months for SRT. Adverse effects-The 3-year rate of freedom from central nervous system adverse effects was 89.7% (72.2% for SRS and 100% for SRT). Three patients who received SRS for a tumor in the cavernous sinus developed a ring enhancement in the temporal lobe as shown by follow-up magnetic resonance imaging. Two of these cases were irreversible and were considered to be radiation necrosis. None of the 48 patients developed new neurocognitive or visual disorders attributable to the irradiation. The incidence of endocrinological adverse effects were similar in the two groups, resulting in 3-year rates of freedom from newly initiated hormonal replacement of 78.4% (77.1% for SRS and 79.9% for SRT). CONCLUSION Considering the relatively high incidence of morbidity observed in the SRS group, we recommend SRT as the primary method of radiation therapy for pituitary tumors. When treating a lesion in the cavernous sinus with SRS, special attention should be paid to dose distribution in the adjacent brain parenchyma. Longer follow-up is necessary before drawing any conclusions about the advantages of these techniques over conventional external beam radiation therapy.
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Affiliation(s)
- M Mitsumori
- The Brain Tumor Center of the Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Buatti JM, Bova FJ, Friedman WA, Meeks SL, Marcus RB, Mickle JP, Ellis TL, Mendenhall WM. Preliminary experience with frameless stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 1998; 42:591-9. [PMID: 9806519 DOI: 10.1016/s0360-3016(98)00276-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To report initial clinical experience with a novel high-precision stereotactic radiotherapy system. METHODS AND MATERIALS Sixty patients ranging in age from 2 to 82 years received a total of 1426 treatments with the University of Florida frameless stereotactic radiotherapy system. Of the total, 39 (65%) were treated with stereotactic radiotherapy (SRT) alone, and 21 (35%) received SRT as a component of radiotherapy. Pathologic diagnoses included meningiomas (15 patients), low-grade astrocytomas (11 patients), germinomas (9 patients), and craniopharyngiomas (5 patients). The technique was used as means of dose escalation in 11 patients (18%) with aggressive tumors. Treatment reproducibility was measured by comparing bite plate positioning registered by infrared light-emitting diodes (IRLEDs) with the stereotactic radiosurgery reference system, and with measurements from each treatment arc for the 1426 daily treatments (5808 positions). We chose 0.3 mm vector translation error and 0.3 degrees rotation about each axis as the maximum tolerated misalignment before treating each arc. RESULTS With a mean follow-up of 11 months, 3 patients had recurrence of malignant disease. Acute side effects were minimal. Of 11 patients with low grade astrocytomas, 4 (36%) had cerebral edema and increased enhancement on MR scans in the first year, and 2 required steroids. All had resolution and marked tumor involution on follow-up imaging. Bite plate reproducibility was as follows. Translational errors: anterior-posterior, 0.01 +/- 0.10; lateral, 0.02 +/- 0.07; axial, 0.01 +/- 0.10. Rotational errors (degrees): anterior-posterior, 0.00 +/- 0.03; lateral, 0.00 +/- 0.06; axial, 0.01 +/- 0.04. No patient treatment was delivered beyond the maximum tolerated misalignment. Daily treatment was delivered in approximately 15 min per patient. CONCLUSION Our initial experience with stereotactic radiotherapy using the infrared camera guidance system was good. Patient selection and treatment strategies are evolving rapidly. Treatment accuracy was the best reported, and the treatment approach was practical.
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Affiliation(s)
- J M Buatti
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville 32610, USA
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Yoon SC, Suh TS, Jang HS, Chung SM, Kim YS, Ryu MR, Choi KH, Son HY, Kim MC, Shinn KS. Clinical results of 24 pituitary macroadenomas with linac-based stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 1998; 41:849-53. [PMID: 9652848 DOI: 10.1016/s0360-3016(98)00124-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the impact of stereotactic radiosurgery (SRS) on the clinical course, hormonal status, and follow-up CT/MRI scan of pituitary macroadenomas. METHODS AND MATERIALS From July 1988 to March 1996, 24 pituitary macroadenomas had been treated using 6 MV linear accelerator based SRS. They consisted of 11 (45.8%) prolactinomas, 2 (8.3%) growth hormone (GH)-secreting tumors, 1 (4.2%) Cushing's disease, 8 (33.3%) nonsecreting (nonfunctioning: NF) tumors, and 2 (8.3%) mixed prolactin-growth hormone (PRL-GH)-secreting tumors (M:F = 12:12; aged 21-61 years). Postoperative irradiation was performed in all cases except for the instance of Cushing's disease. The prescribed dose to tumor center varied from 10 to 27 Gy (mean 21.1 Gy) using a collimator size of 0.5 to 2.5 cm. The follow-up duration ranged from 13 to 89 months (mean 49.2 months). Results from these patients were compared to our results using conventional radiation. RESULTS Visual acuity and field defect were improved or became normal in 19 (79.2%) cases. Four (16.7%) remained unchanged after the treatment. One (4.1%) progressed 6 years after SRS and subsequently had repeat surgery with conventional boost irradiation. Of the 13 (46.4%) prolactinomas, including two mixed PRL-GH secreting tumors, 11 (84.1%) revealed normal hormonal levels within 1 year after SRS. In contrast, it took 2 years to become normal after conventional radiation therapy. In four GH-secreting tumors including two mixed PRL-GH secreting tumors, SRS and conventional methods showed similar responses. On follow-up imagings of the 21 patients, the mass was completely resolved in 4 (16.7%), including 3 PRLs and one NF, decreased in 11 (45.8%), and unchanged in 5 (16.7%) with central necrosis or cysts. One (4.2%) progressed and was reoperated 6 years after treatment. The complications related to SRS were comparable to those from conventional method. CONCLUSION Radiosurgery can be used effectively in patients with pituitary adenoma. In this study, a more rapid hormonal and clinical response was achieved with radiosurgery than with conventional pituitary irradiation treatment.
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Affiliation(s)
- S C Yoon
- Department of Therapeutic Radiology, Catholic University, Kangnam St. Mary's Hospital & Cancer Center, Seoul, Korea
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Delannes M, Bonnet J, Daly-Schveitzer N. [Technical evolution of irradiation in stereotactic conditions: dose fractionation]. Cancer Radiother 1998; 2:160-7. [PMID: 9749110 DOI: 10.1016/s1278-3218(98)89086-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The development of non-invasive head fixation systems, allowing 3D determination of the target coordinates, has lead to the increased use of fractionated stereotactic irradiation. These systems have been checked for accuracy and the mean precision of repositioning has been evaluated to +/- 1 mm. With the mean geometrical accuracy set at +/- 1 mm, a 2 mm safety margin is usually added to the clinical target volume in order to define the planning target volume. Quality assurance procedures must conform to the required precision of the technique while remaining realistic in day-to-day use relative to planned conventional treatments. Biologically different from single dose irradiation, the fractionated stereotactic irradiation completes the range of techniques used in the treatment of intra-cerebral lesions.
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Affiliation(s)
- M Delannes
- Département de radiothérapie, Institut Claudius-Regaud, Toulouse, France
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Lederman G, Arbit E, Odaimi M, Lombardi E, Wrzolek M, Wronski M. Fractionated stereotactic radiosurgery and concurrent taxol in recurrent glioblastoma multiforme: a preliminary report. Int J Radiat Oncol Biol Phys 1998; 40:661-6. [PMID: 9486617 DOI: 10.1016/s0360-3016(97)00843-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Surgery and systemic chemotherapy offer modest benefit to patients with recurrent glioblastoma multiforme. These tumors are associated with rapid growth and progressive neurological deterioration. Radiosurgery offers a rational alternative treatment, delivering intensive local therapy. A pilot protocol to treat recurrent glioblastoma was developed using fractionated stereotactic radiosurgery with concurrent intravenous (i.v.) Taxol as a radiation sensitizer. METHODS AND MATERIALS The treatment outcome was analyzed in 14 patients with recurrent glioblastoma treated with fractionated stereotactic radiosurgery and concurrent Taxol. Median tumor volume was 15.7 cc and patients received a mean radiation dose of 6.2 Gy at 90% isodose line, 4 times weekly. The median dose of Taxol was 120 mg/m2. RESULTS The median survival was 14.2 months, 1-year survival was 50%. CONCLUSIONS Survival for this small group of patients was similar to or better than historical controls or patients treated with single-fraction radiosurgery alone. This data should stimulate the investigation of both fractionated radiosurgery and the development of radiation sensitizers to further enhance treatment.
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Affiliation(s)
- G Lederman
- Department of Radiation Oncology, Staten Island University Hospital, NY 10305, USA.
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Baker KC, Isert PR. Anaesthetic considerations for children undergoing stereotactic radiosurgery. Anaesth Intensive Care 1997; 25:691-5. [PMID: 9452856 DOI: 10.1177/0310057x9702500618] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An anaesthetic case report of children undergoing stereotactic radiosurgery is presented, with a review of the inherent unique anaesthetic challenges. Twelve stereotactic radiosurgery procedures performed at The Prince of Wales Hospital, Sydney, were retrospectively reviewed. Despite differences in approach by individual anaesthetists to managing these children, an overall safe sequence may be evolved. The use of stereotactic radiosurgery for paediatric neuropathology is reviewed. The potential anaesthetic problems related to the paediatric patient and the peculiarities of the procedure are discussed and related to our series.
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Affiliation(s)
- K C Baker
- Department of Anaesthesia, Prince of Wales Hospital, Sydney, N.S.W
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Condra KS, Buatti JM, Mendenhall WM, Friedman WA, Marcus RB, Rhoton AL. Benign meningiomas: primary treatment selection affects survival. Int J Radiat Oncol Biol Phys 1997; 39:427-36. [PMID: 9308947 DOI: 10.1016/s0360-3016(97)00317-9] [Citation(s) in RCA: 213] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To examine the effect of primary treatment selection on outcomes for benign intracranial meningiomas at the University of Florida. METHODS AND MATERIALS For 262 patients, the impact of age, Karnofsky performance status, pathologic features, tumor size, tumor location, and treatment modality on local control and cause-specific survival was analyzed (minimum potential follow-up, 2 years; median follow-up, 8.2 years). Extent of surgery was classified by Simpson grade. Treatment groups: surgery alone (n = 229), surgery and postoperative radiotherapy (RT) (n = 21), RT alone (n = 7), radiosurgery alone (n = 5). Survival analysis: Kaplan-Meier method with univariate and multivariate analysis. RESULTS At 15 years, local control was 76% after total excision (TE) and 87% after subtotal excision plus RT (SE+RT), both significantly better (p = 0.0001) than after SE alone (30%). Cause-specific survival at 15 years was reduced after treatment with SE alone (51%), compared with TE (88%) or SE+RT (86%) (p = 0.0003). Recurrence after primary treatment portended decreased survival, independent of initial treatment group or salvage treatment selection (p = 0.001). Atypical pathologic features predicted reduced 15-year local control (54 vs. 71%) and cause-specific survival rates (57 vs. 86%). Multivariate analysis for cause-specific survival revealed treatment group (SE vs. others; p = 0.0001), pathologic features (atypical vs. typical;p = 0.0056), and Karnofsky performance status (> or = 80 vs. < 80; p = 0.0153) as significant variables. CONCLUSION Benign meningiomas are well managed by TE or SE+RT. SE alone is inadequate therapy and adversely affects cause-specific survival. Atypical pathologic features predict a poorer outcome, suggesting possible benefit from more aggressive treatment. Because local recurrence portends lower survival rates, primary treatment choice is important.
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Affiliation(s)
- K S Condra
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, USA
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Abstract
Brain tumors account for 20% of childhood cancers and provide a "frontier" in which improved disease control and functional outcome require coordinated, directed studies in neurosurgery, radiation therapy, and chemotherapy. Among the several brain tumor types common in children, the recent experiences in medulloblastoma, ependymoma, and tumors occurring in infants and very young children are reviewed in the context of recent clinical trials and ongoing investigations.
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Affiliation(s)
- L E Kun
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Hacker FL, Kooy HM, Bellerive MR, Killoran JH, Leber ZH, Shrieve DC, Tarbell NJ, Loeffler JS. Beam shaping for conformal fractionated stereotactic radiotherapy: a modeling study. Int J Radiat Oncol Biol Phys 1997; 38:1113-21. [PMID: 9276379 DOI: 10.1016/s0360-3016(97)00151-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE The patient population treated with fractionated stereotactic radiotherapy (SRT) is significantly different than that treated with stereotactic radiosurgery (SRS). Generally, lesions treated with SRT are larger, less spherical, and located within critical regions of the central nervous system; hence, they offer new challenges to the treatment planner. Here a simple, cost effective, beam shaping system has been evaluated relative to both circular collimators and an ideal dynamically conforming system for effectiveness in providing conformal therapy for these lesions. METHODS AND MATERIALS We have modeled a simple system for conformal arc therapy using four independent jaws. The jaw positions and collimator angle are changed between arcs but held fixed for the duration of each arc. Eleven previously treated SRT cases have been replanned using this system. The rectangular jaw plans were then compared to the original treatment plans which used circular collimators. The plans were evaluated with respect to tissue sparing at 100%, 80%, 50%, and 20% of the prescription dose. A plan was also done for each tumor in which the beam aperture was continuously conformed to the beams eye view projection of the tumor. This was used as an ideal standard for conformal therapy in the absence of fluence modulation. RESULTS For tumors with a maximum extent of over 3.5 cm the rectangular jaw plans reduced the mean volume of healthy tissue involved at the prescription dose by 57% relative to the circular collimator plans. The ideal conformal plans offered no significant further improvement at the prescription dose. The relative advantage of the rectangular jaw plans decreased at lower isodoses so that at 20% of the prescription dose tissue involvement for the rectangular jaw plans was equivalent to that for the circular collimator plans. At these isodoses the ideal conformal plans gave substantially better tissue sparing. CONCLUSION A simple and economical field shaping device has been shown to provide all of the beam shaping advantage of a hypothetical ideal dynamically conforming system at the prescription level. This system may be immediately implemented in the clinic. It offers a substantial advantage over the currently used circular collimators in the high dose region with equivalent performance in the low dose region.
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Affiliation(s)
- F L Hacker
- Joint Center for Radiation Therapy, Department of Radiation Oncology, Harvard Medical School, Boston, MA 02215, USA.
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