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El-Shehaby AMN, Reda WA, Abdel Karim KM, Nabeel AM, Emad Eldin RM, Tawadros SR. Response to Letter: Radiosurgery for Colloid Cyst - Surgeon Patriarchy or Patient Autonomy? Stereotact Funct Neurosurg 2024:1-2. [PMID: 39326399 DOI: 10.1159/000541145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/16/2024] [Indexed: 09/28/2024]
Affiliation(s)
- Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute For Research and Treatment, Cairo, Egypt
- Neurosurgery Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute For Research and Treatment, Cairo, Egypt
- Neurosurgery Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Khaled M Abdel Karim
- Gamma Knife Center Cairo, Nasser Institute For Research and Treatment, Cairo, Egypt
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute For Research and Treatment, Cairo, Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Nasser Institute For Research and Treatment, Cairo, Egypt
- Neurosurgery Department, Faculty of Medicine, Benha University, Banha, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute For Research and Treatment, Cairo, Egypt
- Neurosurgery Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Shaaban A, Pham D, Tos SM, Mantziaris G, Schlesinger D, Sheehan JP. Biological effective dose as a predictor of local tumor control in stereotactic radiosurgery treated parasellar meningioma patients. J Neurooncol 2024:10.1007/s11060-024-04804-1. [PMID: 39190046 DOI: 10.1007/s11060-024-04804-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/11/2024] [Indexed: 08/28/2024]
Abstract
INTRODUCTION The radio-surgical literature increasingly uses biological effective dose (BED) as a replacement for absorbed dose to analyze outcome of stereotactic radiosurgery (SRS). There are as yet no studies which specifically investigate the association of BED to local tumor control in para-sellar meningioma. METHODS we did a retrospective analysis of patients underwent stereotactic radiosurgery (SRS) for para-sellar meningioma during the period of 1995-2022. Demographic, clinical, SRS parameters, and outcome data were collected. The target margin BED with and without a model for sub-lethal repair was calculated, as well as a ratio of BED at the target margin to the absorbed dose at the target margin. Factors related to local control were further analyzed. RESULTS The study was comprised of 91 patients, 20 (22.0%) and 71 (78.0%) of whom were male and female, respectively. The median age was 55.0 (interquartile range Q1, Q3:47.5,65.5years). 34 (37%) patients had a resection of their meningioma prior to SRS. The median interval from SRS to last clinical follow up or progression was 89 months. 13 (14.3%) patients were found to have progression. 3-, 5- and 10-years local tumor control were 98%, 92% and 77%, respectively. In cox univariate analysis, the following factors were significant: Number of prior surgical resections (Hazard Ratio [HR] = 1.82, 95% CI = 1.08-3.05, p = 0.024), BED (HR = 0.96, 95% CI = 0.92-1.00, p = 0.03), and BED/margin (HR = 0.44, 95% CI = 0.21-0.92, p = 0.028). A BED threshold above 68 Gy was associated significantly with tumor control (P = 0.04). CONCLUSION BED and BED /margin absorbed dose ratio can be predictors of local control after SRS in parasellar meningioma. Optimizing the BED above 68Gy2.47 may afford better long-term tumor control.
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Affiliation(s)
- Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA
| | - Duy Pham
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA
| | - Salem M Tos
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA.
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Yu J, Fu J, Li Y, Hu G, Hu G, Hu W, Liu D, Fu J. Hypopituitarism after gamma knife radiosurgery for pituitary adenomas: long-term results from a single-center experience. BMC Cancer 2024; 24:963. [PMID: 39107688 PMCID: PMC11301991 DOI: 10.1186/s12885-024-12735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVE The aim of this study was to investigate the incidence and risk factors of new-onset hypopituitarism after gamma knife radiosurgery (GKRS) for pituitary adenomas in a single center. METHODS In this retrospective study, 241 pituitary adenoma patients who underwent GKRS from 1993 to 2016 were enrolled. These patients had complete endocrine, imaging, and clinical data before and after GKRS. The median follow-up time was 56.0 (range, 12.7-297.6) months. RESULTS Fifty patients (20.7%) developed new-onset hypopituitarism after GKRS, including hypogonadism (n = 22), hypothyroidism (n = 29), hypocortisolism (n = 20), and growth hormone deficiency (n = 4). The median time to new-onset hypopituitarism was 44.1 (range, 13.5-141.4) months. The rates of new-onset hypopituitarism were 7%, 16%, 20%, 39%, and 45% at 1, 3, 5, 10, and 15 years, respectively. For those patients treated with a single GKRS, sex (p = 0.012), suprasellar extension (p = 0.048), tumor volume (≥ 5 cm3) (p < 0.001), tumor progression (p = 0.001), pre-existing hypopituitarism (p = 0.011), and previous surgery (p = 0.009) were significantly associated with new-onset hypopituitarism in univariate analysis. In the multivariate analysis, tumor volume (≥ 5 cm3) and tumor progression were associated with new-onset hypopituitarism (hazard ratio [HR] = 3.401, 95% confidence interval [CI] = 1.708-6.773, p < 0.001 and HR = 3.594, 95% CI = 1.032-12.516, p = 0.045, respectively). For patients who received 2 or more times GKRS, no risk factors associated with new-onset hypopituitarism were found. CONCLUSION New-onset hypopituitarism was not uncommon after GKRS for pituitary adenomas. In this study, large tumor volume (≥ 5 cm3) and tumor progression were associated with new-onset hypopituitarism after a single GKRS.
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Affiliation(s)
- Jinxiu Yu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Jiaming Fu
- Guangdong Pharmaceutical University, Guangzhou, Guangdong, 510006, China
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China
| | - Guangxin Hu
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China
| | - Guanye Hu
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China
| | - Wentao Hu
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China
| | - Detian Liu
- Department of Neurology, Longgang District Central Hospital of Shenzhen, Shenzhen, Guangdong, 518116, China.
| | - Junyi Fu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China.
- Institute of Neuroscience, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510260, China.
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Cornelissen S, Schouten SM, Langenhuizen PPJH, Lie ST, Kunst HPM, de With PHN, Verheul JB. Defining tumor growth in vestibular schwannomas: a volumetric inter-observer variability study in contrast-enhanced T1-weighted MRI. Neuroradiology 2024:10.1007/s00234-024-03416-w. [PMID: 38980343 DOI: 10.1007/s00234-024-03416-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE For patients with vestibular schwannomas (VS), a conservative observational approach is increasingly used. Therefore, the need for accurate and reliable volumetric tumor monitoring is important. Currently, a volumetric cutoff of 20% increase in tumor volume is widely used to define tumor growth in VS. The study investigates the tumor volume dependency on the limits of agreement (LoA) for volumetric measurements of VS by means of an inter-observer study. METHODS This retrospective study included 100 VS patients who underwent contrast-enhanced T1-weighted MRI. Five observers volumetrically annotated the images. Observer agreement and reliability was measured using the LoA, estimated using the limits of agreement with the mean (LOAM) method, and the intraclass correlation coefficient (ICC). RESULTS The 100 patients had a median average tumor volume of 903 mm3 (IQR: 193-3101). Patients were divided into four volumetric size categories based on tumor volume quartile. The smallest tumor volume quartile showed a LOAM relative to the mean of 26.8% (95% CI: 23.7-33.6), whereas for the largest tumor volume quartile this figure was found to be 7.3% (95% CI: 6.5-9.7) and when excluding peritumoral cysts: 4.8% (95% CI: 4.2-6.2). CONCLUSION Agreement limits within volumetric annotation of VS are affected by tumor volume, since the LoA improves with increasing tumor volume. As a result, for tumors larger than 200 mm3, growth can reliably be detected at an earlier stage, compared to the currently widely used cutoff of 20%. However, for very small tumors, growth should be assessed with higher agreement limits than previously thought.
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Affiliation(s)
- Stefan Cornelissen
- Gamma Knife Center, Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.
| | - Sammy M Schouten
- Gamma Knife Center, Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Otolaryngology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Otolaryngology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Patrick P J H Langenhuizen
- Gamma Knife Center, Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Suan Te Lie
- Gamma Knife Center, Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Henricus P M Kunst
- Department of Otolaryngology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Otolaryngology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Peter H N de With
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Jeroen B Verheul
- Gamma Knife Center, Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Dumot C, Mantziaris G, Dayawansa S, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Abdelsalam AR, Liscak R, May J, Mashiach E, De Nigris Vasconcellos F, Bernstein K, Kondziolka D, Speckter H, Mota R, Brito A, Bindal SK, Niranjan A, Lunsford DL, Benjamin CG, Abrantes de Lacerda Almeida T, Mao J, Mathieu D, Tourigny JN, Tripathi M, Palmer JD, Matsui J, Crooks J, Wegner RE, Shepard MJ, Vance ML, Sheehan JP. Stereotactic radiosurgery for nonfunctioning pituitary tumor: A multicenter study of new pituitary hormone deficiency. Neuro Oncol 2024; 26:715-723. [PMID: 38095431 PMCID: PMC10995514 DOI: 10.1093/neuonc/noad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is used to treat recurrent or residual nonfunctioning pituitary neuroendocrine tumors (NFPA). The objective of the study was to assess imaging and development of new pituitary hormone deficiency. METHODS Patients treated with single-session SRS for a NFPA were included in this retrospective, multicenter study. Tumor control and new pituitary dysfunction were evaluated using Cox analysis and Kaplan-Meier curves. RESULTS A total of 869 patients (male 476 [54.8%], median age at SRS 52.5 years [Interquartile range (IQR): 18.9]) were treated using a median margin dose of 14Gy (IQR: 4) for a median tumor volume of 3.4 cc (IQR: 4.3). With a median radiological follow-up of 3.7 years (IQR: 4.8), volumetric tumor reduction occurred in 451 patients (51.9%), stability in 364 (41.9%) and 54 patients (6.2%) showed tumor progression.The probability of tumor control was 95.5% (95% Confidence Interval [CI]: 93.8-97.3) and 88.8% (95%CI: 85.2-92.5) at 5 and 10 years, respectively. A margin dose >14 Gy was associated with tumor control (Hazard Ratio [HR]:0.33, 95% CI: 0.18-0.60, P < 0.001). The probability of new hypopituitarism was 9.9% (95% CI: 7.3-12.5) and 15.3% (95% CI: 11-19.4) at 5 and 10 years, respectively. A maximum point dose >10 Gy in the pituitary stalk was associated with new pituitary hormone deficiency (HR: 3.47, 95% CI: 1.95-6.19). The cumulative probability of new cortisol, thyroid, gonadotroph, and growth hormone deficiency was 8% (95% CI: 3.9-11.9), 8.3% (95% CI: 3.9-12.5), 3.5% (95% CI: 1.7-5.2), and 4.7% (95% CI: 1.9-7.4), respectively at 10 years. CONCLUSIONS SRS provides long-term tumor control with a 15.3% risk of hypopituitarism at 10 years.
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Affiliation(s)
- Chloe Dumot
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
- Department of Neurological Surgery, Hospices civils de Lyon, Lyon, France
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sam Dayawansa
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Departments of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Departments of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Departments of Clinical Oncology, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Departments of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, James Cancer Hospital at The Ohio State University, Columbus, Ohio, USA
| | - Elad Mashiach
- Department of Neurosurgery, NYU Langone, New York City, New York, USA
| | | | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone, New York City, New York, USA
| | | | - Herwin Speckter
- Departments of Neurosurgery, Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Ruben Mota
- Departments of Neurosurgery, Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Anderson Brito
- Departments of Neurosurgery, Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Shray Kumar Bindal
- Departments of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Departments of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dade L Lunsford
- Departments of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | - Jennifer Mao
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, James Cancer Hospital at The Ohio State University, Columbus, Ohio, USA
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Jean-Nicolas Tourigny
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Manjul Tripathi
- Departments of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joshua David Palmer
- Department of Radiation Oncology, James Cancer Hospital at The Ohio State University, Columbus, Ohio, USA
| | - Jennifer Matsui
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, James Cancer Hospital at The Ohio State University, Columbus, Ohio, USA
| | - Joe Crooks
- College of Medecine, Drexel University, Philadelphia, Pennsylvania, USA
| | - Rodney E Wegner
- Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Matthew J Shepard
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Mary Lee Vance
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Kara M, Yılmaz M, Şengöz M, Peker S. Hormonal and radiologic outcomes after gamma knife radiosurgery for nonfunctioning pituitary adenomas. Br J Neurosurg 2024; 38:486-492. [PMID: 33792443 DOI: 10.1080/02688697.2021.1903388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 02/02/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gamma knife radiosurgery (GKRS) is an established treatment option for residual and recurrent nonfunctioning pituitary adenoma (NFPA). This investigation assessed hormonal and radiologic outcomes after adjuvant and primary GKRS for NFPAs. METHODS This retrospective study included 252 patients with NFPA who underwent GKRS at a single center between 2005 and 2016. GKRS was performed as adjuvant procedure in 216 (85.8%) patients and as primary procedure in 36 (14.2%) patients. Characteristics of these two groups were compared. RESULTS Mean age was comparable between adjuvant and primary GKRS groups (48.3 ± 12.6 vs. 52.2 ± 13.2 years, respectively, p > 0.05). Adjuvant GKRS and primary GKRS groups were similar in terms of the mean prescribed radiation dose and tumor volume (15.1 ± 2.7 vs. 15.3 ± 1.9 Gy and 4.2 ± 3.6 vs. 3.1 ± 2.5 cm3, respectively, p > 0.05 for both). The rate of endocrine deficiency during 5-year follow-up showed similar trend in adjuvant and primary GKRS groups (3.7%, 8.7%, and 14.8% vs. 5.6%, 13.9%, and 27.8% at first, third, and fifth year time points, respectively). Tumor control rates were also similar (98.6%, 96.3%, and 93% vs. 100%, 97.3%, and 94.5% at first, third, and fifth year time points, respectively). In both groups, tumor volume >5 cm3 was associated with higher rate of hypopituitarism and tumor progression. CONCLUSIONS GKRS was effective both as adjuvant and primary procedure in patients with NFPA. Radiation dose of ≤13.5 Gy was associated with lower tumor control rate and tumor volume >5 cm3 was associated with higher rates of hypopituitarism and tumor progression.
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Affiliation(s)
- Müjdat Kara
- Department of Endocrinology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Meltem Yılmaz
- Department of Medical Biotechnology, Acibadem University, Istanbul, Turkey
| | - Meriç Şengöz
- Department of Radiation Oncology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Selçuk Peker
- Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
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Balossier A, Sahgal A, Kotecha R, Fariselli L, Gorgulho A, Levivier M, Ma L, Paddick I, Pollock BE, Sheehan JP, Suh JH, Yomo S, Zhang Z, Regis J. Management of sporadic intracanalicular vestibular schwannomas: A critical review and International Stereotactic Radiosurgery Society (ISRS) practice guidelines. Neuro Oncol 2024; 26:429-443. [PMID: 38134966 PMCID: PMC10912008 DOI: 10.1093/neuonc/noad253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The choice of an appropriate strategy for intracanalicular vestibular schwannoma (ICVS) is still debated. We conducted a systematic review and meta-analysis with the aim to compare treatment outcomes amongst management strategies (conservative surveillance (CS), microsurgical resection (MR), or stereotactic radiosurgery (SRS)) aiming to inform guideline recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS Using PRISMA guidelines, we reviewed manuscripts published between January 1990 and October 2021 referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical studies or case series reporting a cohort of ICVS managed with CS, MR, or SRS. Primary outcome measures included tumor control, the need for additional treatment, hearing outcomes, and posttreatment neurological deficits. These were pooled using meta-analytical techniques and compared using meta-regression with random effect. RESULTS Forty studies were included (2371 patients). The weighted pooled estimates for tumor control were 96% and 65% in SRS and CS series, respectively (P < .001). Need for further treatment was reported in 1%, 2%, and 25% for SRS, MR, and CS, respectively (P = .001). Hearing preservation was reported in 67%, 68%, and 55% for SRS, MR, and CS, respectively (P = .21). Persistent facial nerve deficit was reported in 0.1% and 10% for SRS and MR series, respectively (P = .01). CONCLUSIONS SRS is a noninvasive treatment with at least equivalent rates of tumor control and hearing preservation as compared to MR, with the caveat of better facial nerve preservation. As compared to CS, upfront SRS is an effective treatment in achieving tumor control with similar rates of hearing preservation.
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Affiliation(s)
- Anne Balossier
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Institut de Neurosciences des Systèmes (INS) UMR1106, Marseille, France
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
| | - Alessandra Gorgulho
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, and, D’Or Institute for Research and Education, São Paulo, Brazil
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Zhenwei Zhang
- Center of Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
| | - Jean Regis
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Institut de Neurosciences des Systèmes (INS) UMR1106, Marseille, France
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8
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Putz F, Bock M, Schmitt D, Bert C, Blanck O, Ruge MI, Hattingen E, Karger CP, Fietkau R, Grigo J, Schmidt MA, Bäuerle T, Wittig A. Quality requirements for MRI simulation in cranial stereotactic radiotherapy: a guideline from the German Taskforce "Imaging in Stereotactic Radiotherapy". Strahlenther Onkol 2024; 200:1-18. [PMID: 38163834 PMCID: PMC10784363 DOI: 10.1007/s00066-023-02183-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024]
Abstract
Accurate Magnetic Resonance Imaging (MRI) simulation is fundamental for high-precision stereotactic radiosurgery and fractionated stereotactic radiotherapy, collectively referred to as stereotactic radiotherapy (SRT), to deliver doses of high biological effectiveness to well-defined cranial targets. Multiple MRI hardware related factors as well as scanner configuration and sequence protocol parameters can affect the imaging accuracy and need to be optimized for the special purpose of radiotherapy treatment planning. MRI simulation for SRT is possible for different organizational environments including patient referral for imaging as well as dedicated MRI simulation in the radiotherapy department but require radiotherapy-optimized MRI protocols and defined quality standards to ensure geometrically accurate images that form an impeccable foundation for treatment planning. For this guideline, an interdisciplinary panel including experts from the working group for radiosurgery and stereotactic radiotherapy of the German Society for Radiation Oncology (DEGRO), the working group for physics and technology in stereotactic radiotherapy of the German Society for Medical Physics (DGMP), the German Society of Neurosurgery (DGNC), the German Society of Neuroradiology (DGNR) and the German Chapter of the International Society for Magnetic Resonance in Medicine (DS-ISMRM) have defined minimum MRI quality requirements as well as advanced MRI simulation options for cranial SRT.
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Affiliation(s)
- Florian Putz
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Michael Bock
- Klinik für Radiologie-Medizinphysik, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Daniela Schmitt
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Christoph Bert
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Maximilian I Ruge
- Klinik für Stereotaxie und funktionelle Neurochirurgie, Zentrum für Neurochirurgie, Universitätsklinikum Köln, Cologne, Germany
| | - Elke Hattingen
- Institut für Neuroradiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Christian P Karger
- Abteilung Medizinische Physik in der Strahlentherapie, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
- Nationales Zentrum für Strahlenforschung in der Onkologie (NCRO), Heidelberger Institut für Radioonkologie (HIRO), Heidelberg, Germany
| | - Rainer Fietkau
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johanna Grigo
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel A Schmidt
- Neuroradiologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Bäuerle
- Radiologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andrea Wittig
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Würzburg, Würzburg, Germany
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9
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Shinya Y, Hasegawa H, Shin M, Kawashima M, Umekawa M, Katano A, Ikemura M, Ushiku T, Ohara K, Okano A, Teranishi Y, Miyawaki S, Saito N. Long-Term Outcomes of Stereotactic Radiosurgery for Postoperative World Health Organization Grade I Skull Base Meningioma: Utility of Ki-67 Labeling Index as a Prognostic Indicator. Neurosurgery 2023; 93:1144-1153. [PMID: 37283526 DOI: 10.1227/neu.0000000000002546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/06/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Gross total resection, without causing neurological deficits, is challenging in skull base meningioma (SBM). Therefore, stereotactic radiosurgery (SRS) is an important approach for SBMs; however, it is difficult to predict the long-term prognosis. OBJECTIVE To identify the predictive factors for tumor progression after SRS for World Health Organization (WHO) grade I SBMs, focusing on the Ki-67 labeling index (LI). METHODS In this single-center retrospective study, factors affecting progression-free survival rates (PFSs) and neurological outcomes in patients undergoing SRS for postoperative SBMs were evaluated. Based on the Ki-67 LI, patients were classified into 3 groups: low (<4%), intermediate (4%-6%), and high LI (>6%). RESULTS In the 112 patients enrolled, the cumulative 5- and 10-year PFSs were 93% and 83%, respectively. The PFSs were significantly higher in the low LI group (95% at 10 years) compared with the other groups (intermediate LI, 60% at 10 years, P = .007; high LI, 20% at 10 years, P = .001). Multivariable Cox proportional hazard analysis demonstrated that the Ki-67 LI was significantly associated with the PFSs (low vs intermediate LI; hazard ratio, 6.00; 95% CI, 1.41-25.54; P = .015; low vs high LI; hazard ratio, 31.90; 95% CI, 5.59-181.77; P = .001). CONCLUSION Ki-67 LI may be a useful predictor of long-term prognosis in SRS for postoperative WHO grade I SBM. SRS provides excellent long- and mid-term PFSs in SBMs with Ki-67 LIs <4% or 4% to 6%, with a low risk of radiation-induced adverse events.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo , Japan
| | - Masako Ikemura
- Department of Pathology, The University of Tokyo Hospital, Tokyo , Japan
| | - Tetsuo Ushiku
- Department of Pathology, The University of Tokyo Hospital, Tokyo , Japan
| | - Kenta Ohara
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Atsushi Okano
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Yu Teranishi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo , Japan
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10
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Jablonska PA, Galán N, Barranco J, Leon S, Robledano R, Echeveste JI, Calvo A, Aristu J, Serrano D. Presence of Activated (Phosphorylated) STAT3 in Radiation Necrosis Following Stereotactic Radiosurgery for Brain Metastases. Int J Mol Sci 2023; 24:14219. [PMID: 37762522 PMCID: PMC10532304 DOI: 10.3390/ijms241814219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Brain radiation necrosis (RN) is a subacute or late adverse event following radiotherapy, involving an exacerbated inflammatory response of the brain tissue. The risk of symptomatic RN associated with stereotactic radiosurgery (SRS) as part of the treatment of brain metastases (BMs) has been a subject of recent investigation. The activation of the signal transducer and activator of transcription 3 (STAT3) was shown in reactive astrocytes (RA) associated with BMs. Given that the pathophysiological mechanisms behind RN are not fully understood, we sought to investigate the role of STAT3 among other inflammatory markers in RN development. A mouse model of RN using clinical LINAC-based SRS was designed to induce brain necrosis with the administration of 50 Gy in a single fraction to the left hemisphere using a circular collimator of 5 mm diameter. Immunohistochemistry and multiplex staining for CD4, CD8, CD68, GFAP, and STAT3 were performed. For validation, eleven patients with BMs treated with SRS who developed symptomatic RN and required surgery were identified to perform staining for CD68, GFAP, and STAT3. In the mouse model, the RN and perinecrotic areas showed significantly higher staining for F4/80+ and GFAP+ cells, with a high infiltration of CD4 and CD8 T-lymphocytes, when compared to the non-irradiated cerebral hemisphere. A high number of GFAP+pSTAT3+ and F4/80+pSTAT3+ cells was found in the RN areas and the rest of the irradiated hemisphere. The analysis of human brain specimens showed that astrocytes and microglia were actively phosphorylating STAT3 in the areas of RN and gliosis. Phosphorylated STAT3 is highly expressed in the microglia and RA pertaining to the areas of brain RN. Targeting STAT3 via inhibition represents a promising strategy to ameliorate symptomatic RN in BM patients undergoing SRS.
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Affiliation(s)
- Paola Anna Jablonska
- Department of Radiation Oncology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Nuria Galán
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
| | - Jennifer Barranco
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
| | - Sergio Leon
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
- Department of Pathological Anatomy, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Ramón Robledano
- Department of Pathological Anatomy, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - José Ignacio Echeveste
- Department of Pathological Anatomy, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Alfonso Calvo
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology and Proton Therapy Unit, Clinica Universidad de Navarra, 28027 Madrid, Spain;
| | - Diego Serrano
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
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11
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Hung JSE, Su YH, Chen CJ, Chiang CL, Shen CI, Yang HC, Shiau CY, Luo YH, Wu HM, Hu YS, Lin CJ, Liu KD, Chung WY, Guo WY, Lee CC. Is it advisable to perform radiosurgery for EGFR-TKI-controlled brain metastases? A retrospective study of the role of radiosurgery in lung cancer treatment. J Neurooncol 2023; 164:413-422. [PMID: 37656378 DOI: 10.1007/s11060-023-04425-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Given the availability of TKIs with high central nervous system efficacy, the question arises as to whether upfront SRS provides additional clinical benefits. The goal of this study was to characterize the clinical outcomes of SRS as salvage therapy for TKI-uncontrolled BMs. METHODS This retrospective study included EGFR-mutant NSCLC patients presenting BMs at the time of primary tumor diagnosis. BMs were categorized into three subgroups, referred to as "Nature of TKI-treated BMs", "TKI-controlled brain metastases ± SRS", and "SRS salvage therapy". The first subgroup analysis characterized the effects of TKIs on tumor behavior. In the second subgroup, we compared outcomes of TKI-controlled BMs treated with TKI alone versus those treated with combined TKI-SRS therapy. The third subgroup characterized the outcomes of TKI-uncontrolled BMs treated with SRS as salvage therapy Clinical outcomes include local and distant tumor control. RESULTS This study included 106 patients with a total of 683 BMs. TKI treatment achieved control in 63% of local tumors at 24 months. Among the TKI-controlled BMs, local tumor control was significantly higher in the combined TKI-SRS group (93%) than in the TKI-alone group (65%) at 24 months (p < 0.001). No differences were observed between the two groups in terms of distant tumor control (p = 0.832). In dealing with TKI-uncontrolled BMs, salvage SRS achieved local tumor control in 58% of BMs at 24 months. CONCLUSIONS While upfront TKI alone proved highly effective in BM control, this study also demonstrated the outcomes of SRS when implemented concurrently with TKI or as salvage therapy for TKI-uncontrolled BMs. This study also presents a strategy of the precise timing and targeting of SRS to lesions in progression.
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Affiliation(s)
- Joseph Shang-En Hung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yan-Hua Su
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Chi-Lu Chiang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-I Shen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Hung Luo
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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12
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Balossier A, Delsanti C, Troude L, Thomassin JM, Roche PH, Régis J. Assessing Tumor Volume for Sporadic Vestibular Schwannomas: A Comparison of Methods of Volumetry. Stereotact Funct Neurosurg 2023; 101:265-276. [PMID: 37531945 DOI: 10.1159/000531337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/16/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION The size of vestibular schwannomas (VS) is a major factor guiding the initial decision of treatment and the definition of tumor control or failure. Accurate measurement and standardized definition are mandatory; yet no standard exist. Various approximation methods using linear measures or segmental volumetry have been reported. We reviewed different methods of volumetry and evaluated their correlation and agreement using our own historical cohort. METHODS We selected patients treated for sporadic VS by Gammaknife radiosurgery (GKRS) in our department. Using the stereotactic 3D T1 enhancing MRI on the day of GKRS, 4 methods of volumetry using linear measurements (5-axis, 3-axis, 3-axis-averaged, and 1-axis) and segmental volumetry were compared to each other. The degree of correlation was evaluated using an intraclass correlation test (ICC 3,1). The agreement between the different methods was evaluated using Bland-Altman diagrams. RESULTS A total of 2,188 patients were included. We observed an excellent ICC between 5-axis volumetry (0.98), 3-axis volumetry (0.96), and 3-axis-averaged volumetry (0.96) and segmental volumetry, respectively, irrespective of the Koos grade or Ohata classification. The ICC for 1-axis volumetry was lower (0.72) and varied depending on the Koos and Ohata subgroups. None of these methods were substitutable. CONCLUSION Although segmental volumetry is deemed the most accurate method, it takes more effort and requires sophisticated computation systems compared to methods of volumetry using linear measurements. 5-axis volumetry affords the best adequacy with segmental volumetry among all methods under assessment, irrespective of the shape of the tumor. 1-axis volumetry should not be used.
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Affiliation(s)
- Anne Balossier
- Functional and Stereotactic Neurosurgery, AP-HM, Timone Hospital, Marseille, France
- INSERM, INS, Inst Neurosci Syst, Aix Marseille University, Marseille, France
| | - Christine Delsanti
- Functional and Stereotactic Neurosurgery, AP-HM, Timone Hospital, Marseille, France
| | - Lucas Troude
- Department of Neurosurgery, AP-HM, North University Hospital, Marseille, France
| | - Jean-Marc Thomassin
- Department of Head and Neck Surgery, AP-HM, Timone Hospital, Marseille, France
| | - Pierre-Hugues Roche
- Department of Neurosurgery, AP-HM, North University Hospital, Marseille, France
| | - Jean Régis
- Functional and Stereotactic Neurosurgery, AP-HM, Timone Hospital, Marseille, France
- INSERM, INS, Inst Neurosci Syst, Aix Marseille University, Marseille, France
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13
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Jablonska PA, Muniz T, Ribeiro M, Liu ZA, Ye XY, Devaraja K, Laperriere N, Millar BA, Conrad T, Kongkham P, Butler M, Shultz DB. Toxicity and outcomes of melanoma brain metastases treated with stereotactic radiosurgery: the risk of subsequent symptomatic intralesional hemorrhage exceeds that of radiation necrosis. J Neurooncol 2023; 164:199-209. [PMID: 37552363 DOI: 10.1007/s11060-023-04404-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE We aimed to assess the outcomes and patterns of toxicity in patients with melanoma brain metastases (MBM) treated with stereotactic radiosurgery (SRS) with or without immunotherapy (IO). METHODS From a prospective registry, we reviewed MBM patients treated with single fraction Gamma Knife SRS between 2008 and 2021 at our center. We recorded all systemic therapies (chemotherapy, targeted therapy, or immunotherapy) administered before, during, or after SRS. Patients with prior brain surgery were excluded. We captured adverse events following SRS, including intralesional hemorrhage (IH), radiation necrosis (RN) and local failure (LF), as well as extracranial disease status. Distant brain failure (DBF), extracranial progression-free survival (PFS) and overall survival (OS) were determined using a cumulative Incidence function and the Kaplan-Meier method. RESULTS Our analysis included 165 patients with 570 SRS-treated MBM. Median OS for patients who received IO was 1.41 years versus 0.79 years in patients who did not (p = 0.04). Ipilimumab monotherapy was the most frequent IO regimen (30%). In the absence of IO, the cumulative incidence of symptomatic (grade 2 +) RN was 3% at 24 months and remained unchanged with respect to the type or timing of IO. The incidence of post-SRS g2 + IH in patients who did not receive systemic therapy was 19% at 1- and 2 years compared to 7% at 1- and 2 years among patients who did (HR: 0.33, 95% CI 0.11-0.98; p = 0.046). Overall, neither timing nor type of IO correlated to rates of DBF, OS, or LF. Among patients treated with IO, the median time to extracranial PFS was 5.4 months (95% IC 3.2 - 9.1). CONCLUSION The risk of g2 + IH exceeds that of g2 + RN in MBM patients undergoing SRS, with or without IO. IH should be considered a critical adverse event following MBM treatments.
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Affiliation(s)
- Paola A Jablonska
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Thiago Muniz
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Mauricio Ribeiro
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Xiang Y Ye
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Kaviya Devaraja
- Department of Medical Science, University of Toronto Institute and Princess Margaret Cancer Research Tower, Toronto, Canada
| | - Normand Laperriere
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Barbara-Ann Millar
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Tatiana Conrad
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Paul Kongkham
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Marcus Butler
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - David B Shultz
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
- , 700 University Avenue, 7Th Floor (Room 7-401), Toronto, ON, M5G 1Z5, Canada.
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14
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Pseudoprogression of Vestibular Schwannoma after Stereotactic Radiosurgery with Cyberknife ®: Proposal for New Response Criteria. Cancers (Basel) 2023; 15:cancers15051496. [PMID: 36900290 PMCID: PMC10000564 DOI: 10.3390/cancers15051496] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/05/2023] Open
Abstract
(1) Background: Transient increase in volume of vestibular schwannomas (VS) after stereotactic radiosurgery (SRS) is common and complicates differentiation between treatment-related changes (pseudoprogression, PP) and tumor recurrence (progressive disease, PD). (2) Methods: Patients with unilateral VS (n = 63) underwent single fraction robotic-guided SRS. Volume changes were classified according to existing RANO criteria. A new response type, PP, with a >20% transient increase in volume was defined and divided into early (within the first 12 months) and late (>12 months) occurrence. (3) Results: The median age was 56 (range: 20-82) years, the median initial tumor volume was 1.5 (range: 0.1-8.6) cm3. The median radiological and clinical follow-up time was 66 (range: 24-103) months. Partial response was observed in 36% (n = 23), stable disease in 35% (n = 22) and PP in 29% (n = 18) of patients. The latter occurred early (16%, n = 10) or late (13%, n = 8). Using these criteria, no case of PD was observed. (4) Conclusion: Any volume increase after SRS for vs. assumed to be PD turned out to be early or late PP. Therefore, we propose modifying RANO criteria for SRS of VS, which may affect the management of vs. during follow-up in favor of further observation.
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15
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Bankole NDA, Melhaoui A, Arkha Y, Semmar A, Bouyakhlef K, Jiddane M, El Khamlichi A. Outcomes of single brain metastasis treated with gamma knife stereotaxic radiosurgery(GKSR). Our experience on 103 cases. IBRO Neurosci Rep 2023; 14:138-145. [PMID: 36819774 PMCID: PMC9931898 DOI: 10.1016/j.ibneur.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
Background Brain metastases (BM) occur in the natural course of malignant tumors in 18-40% of cases. Their management has changed considerably over the past decade thanks to the advent of Gamma knife Stereotactic Radiosurgery (GKSR). Objective We report our experience on Single Brain metastasis treated with (GKSR). Methods Patients treated by Gamma Knife stereotaxic radiosurgery (GKSR) in our institution between 2009 and 2021 for Single BM were recorded retrospectively. Results A total of 103 patients (n = 52; 50.5% females) were included, with a mean age of 56.33 ± 11.33. Breast (n = 39, 37.9%) and lung (n = 36, 35%) were the common original location for the primary tumors. GKSR alone without prior surgery, radiotherapy, or chemotherapy was achieved in 81.5% (n = 84). Thirteen patients (15.1%) progressed in BM volume while finding the appearance of de novo BM in 5 (5.8%) patients. The median percentage of tumor control after radiosurgery treatment was 70% (IQR: 65-78) and only 26.2% (n = 27) of patients had > 80% tumor control and stability over the median follow-up time of 5 (95% CI, 4-6) months. We found only two cases of radionecrosis (1.9%). The median survival time was 5.21 (IQR, 3-8) months. Retreatment, recursive partitioning analysis (RPA) class, and tumor stability influenced the overall survival of BM respectively (Hazard Ratio adjust (HRa)= 5.610,p = 0.045; HRa= 6.133,p = 0.031; HRa= 22.463, p = 0.036). Conclusion Stereotaxic Radiosurgery provides good results in terms of Overall survival with fewer neurocognitive disorders.RPA class and tumor control (stability) influenced the overall survival of single BM.
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Affiliation(s)
- Nourou Dine Adeniran Bankole
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco,Corresponding author at: Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco.
| | - Adyl Melhaoui
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco
| | - Yasser Arkha
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco
| | - Afaf Semmar
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco
| | - Khalid Bouyakhlef
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco
| | - Mohamed Jiddane
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco
| | - Abdeslam El Khamlichi
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Ibn Sina University Hospital, Rabat, Morocco,Faculty of Medicine and Pharmacy, Mohamed V University of Rabat, Morocco
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16
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Huang Y, Liang E, Schaff EM, Zhao B, Snyder KC, Chetty IJ, Shah MM, Siddiqui SM. Impact of MRI resolution for Linac-based stereotactic radiosurgery. Front Oncol 2023; 13:1090582. [PMID: 36761944 PMCID: PMC9902927 DOI: 10.3389/fonc.2023.1090582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Objective Magnetic resonance imaging (MRI) is a standard imaging modality in intracranial stereotactic radiosurgery (SRS) for defining target volumes. However, wide disparities in MRI resolution exist, which could directly impact accuracy of target delineation. Here, sequences with various MRI resolution were acquired on phantoms to evaluate the effect on volume definition and dosimetric consequence for cranial SRS. Materials/Methods Four T1-weighted MR sequences with increasing 3D resolution were compared, including two Spin Echo (SE) 2D acquisitions with 5mm and 3mm slice thickness (SE5mm, SE3mm) and two gradient echo 3D acquisitions (TFE, BRAVO). The voxel sizes were 0.4×0.4×5.0, 0.5×0.5×3.0, 0.9×0.9×1.25, and 0.4×0.4×0.5 mm3, respectively. Four phantoms with simulated lesions of different shape and volume (range, 0.53-25.0 cm3) were imaged, resulting in 16 total sets of MRIs. Four radiation oncologists provided contours on individual MR image set. All observer contours were compared with ground truth, defined on CT image according to the absolute dimensions of the target structure, using Dice similarity coefficient (DSC), Hausdorff distance (HD), mean distance-to-agreement (MDA), and the ratio between reconstructed and true volume (Ratiovol ). For dosimetric consequence, SRS plans targeting observer volumes were created. The true Paddick conformity index ( C I p a d d i c k t r u e ), calculated with true target volume, was correlated with quality of observer volume. Results All measures of observer contours improved as increasingly higher MRI resolution was provided from SE5mm to BRAVO. The improvement in DSC, HD and MDA was statistically significant (p<0.01). Dosimetrically, C I p a d d i c k t r u e strongly correlated with DSC of the planning observer volume (Pearson's r=0.94, p<0.00001). Conclusions Significant improvement in target definition and reduced inter-observer variation was observed as the MRI resolution improved, which also improved the quality of SRS plans. Results imply that high resolution 3D MR sequences should be used to minimize potential errors in target definition, and multi-slice 2D sequences should be avoided.
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Huang YH, Yang HC, Chiang CL, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Lee CC. Gamma Knife Radiosurgery Irradiation of Surgical Cavity of Brain Metastases: Factor Analysis and Gene Mutations. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010236. [PMID: 36676186 PMCID: PMC9864800 DOI: 10.3390/life13010236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
(1) Background: Surgical resection for the removal of brain metastases often fails to prevent tumor recurrence within the surgical cavity; hence, researchers are divided as to the benefits of radiation treatment following surgical resection. This retrospective study assessed the effects of post-operative stereotactic radiosurgery (SRS) on local tumor control and overall survival. (2) Methods: This study examined the demographics, original tumor characteristics, and surgical outcomes of 97 patients who underwent Gamma Knife Radiosurgery (GKRS) treatment (103 brain metastases). Kaplan-Meier plots and Cox regression were used to correlate clinical features to tumor control and overall survival. (3) Results: The overall tumor control rate was 75.0% and overall 12-month survival was 89.6%. Tumor control rates in the radiation group versus the non-radiation group were as follows: 12 months (83.1% vs. 57.7%) and 24 months (66.1% vs. 50.5%). During the 2-year follow-up period after SRS, the intracranial response rate was higher in the post-craniotomy radiation group than in the non-radiation group (p = 0.027). Cox regression multivariate analysis determined that post-craniotomy irradiation of the surgical cavity is predictive of tumor control (p = 0.035). However, EGFR mutation was not predictive of overall survival or tumor control. (4) Conclusions: Irradiating the surgical cavity after surgery can enhance local tumor control; however, it does not have a significant effect on overall survival.
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Affiliation(s)
- Yi-Han Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Correspondence: ; Tel.: +886-2-28712121
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18
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Hu YS, Lee CC, Wu CA, Lin CJ, Yang HC, Guo WY, Liu KD, Chung WY, Shiau CY, Wu HM. Magnetic resonance imaging signal characteristics associated with prognosis of skull base chordoma after gamma knife radiosurgery. J Neurooncol 2023; 161:45-56. [PMID: 36565364 DOI: 10.1007/s11060-022-04199-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/14/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the association between the magnetic resonance imaging (MRI) signal characteristics of skull base chordoma and radiosurgical outcomes. METHODS Twenty-four patients with skull base chordomas treated with Gamma Knife radiosurgery (GKRS) after previous surgical resection were retrospectively (2001-2021) examined. Pre-GKRS MRIs were analyzed for RT2 (tumor-to-brainstem signal intensity ratio on T2-weighted imaging), RCE (tumor-to-brainstem signal intensity ratio on contrast-enhanced T1-weighted imaging), and mean apparent diffusion coefficient (ADC). Correlations of the parameters with patient survival and local tumor progression were made by using Cox regression and Kaplan-Meier analyses. RESULTS During a median follow-up of 46 months after GKRS, 9 patients died with significantly more local tumor progression events (median number: 2 vs 0, P = .012) than did 15 alive patients. On multivariable analysis, higher mean ADC was associated with longer patient survival (P = .016) after GKRS. The actuarial 5-year overall survival rates were 88.9% versus 54.7% for chordomas with an ADC of ≥ 1270 × 10-6 mm2/s versus < 1270 × 10-6 mm2/s. RT2 < 1.5 (P = .038) and RCE > 1.57 (P = .022) were associated with a lower probability of local tumor control. CONCLUSION Lower mean ADC values are associated with shorter patient survival in skull base chordomas after GKRS. Diffusion-weighted imaging may help in GKRS planning and outcome prediction for these patients.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, New Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-An Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan.,Department of Radiology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Radiology, Taipei Veterans General Hospital, No. 201, Shipai Rd., Sec. 2, Beitou District, Taipei, 112, Taiwan.
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19
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Liu CW, Yang HC, Chiang CL, Shen CI, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Leukoencephalopathy in patients with brain metastases who received radiosurgery with or without whole brain radiotherapy. J Neurooncol 2023; 161:85-95. [PMID: 36544061 DOI: 10.1007/s11060-022-04210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whole brain radiation therapy (WBRT) for brain metastases (BMs) is a common cause of radiation-induced leukoencephalopathy; however the safety of alternative stereotactic radiosurgery (SRS) remains unclear. This study examined the incidence of leukoencephalopathy in patients treated with SRS alone versus WBRT plus SRS for BMs with a focus on the relationship between prognostic factors and leukoencephalopathy. METHODS Analysis was performed between 2002 and 2021. The total enrollment was 993 patients with the distribution: WBRT plus SRS (n = 291) and SRS only (n = 702). Leukoencephalopathy was graded from 0 to 3 for changes in white matter indicated by the MRI after WBRT or SRS. Patient characteristics and SRS dosimetric parameters were reviewed to identify factors that contributed to the incidence of leukoencephalopathy or overall survival. RESULTS The incidence of leukoencephalopathy was consistently higher in WBRT plus SRS group than in SRS alone group (p < 0.001). Leukoencephalopathy was also associated with a larger total tumor volume (≧28cm3; p = 0.028) and age (> 77 years; p = 0.025). Nonetheless, the SRS integral dose to skull in the subgroup of WBRT plus SRS treatment was not demonstrated significance in development of leukoencephalopathy (p = 0.986 for integral dose 1-2 J, p = 0.776 for integral dose > 2 J). CONCLUSIONS This study revealed that SRS is safe for oligo-BMs in terms of leukoencephalopathy development. Patient age and total tumor volume were identified as important factors in assessing the development of leukoencephalopathy. The additional of SRS (even at an integral dose > 2 J) did not increase the incidence of leukoencephalopathy.
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Affiliation(s)
- Chan-Wei Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-I Shen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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20
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Huang SH, Chuang CC, Wang CC, Wei KC, Chen HC, Hsu PW. Risk factors for peritumoral edema after radiosurgery for intracranial benign meningiomas: a long-term follow-up in a single institution. Neurosurg Focus 2022; 53:E7. [DOI: 10.3171/2022.8.focus22377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Peritumoral edema (PTE) is recognized as a complication following stereotactic radiosurgery (SRS). The aim of this paper was to evaluate the risk of post-SRS PTE for intracranial benign meningiomas and determine the predictive factors.
METHODS
Between 2006 and 2021, 227 patients with 237 WHO grade I meningiomas were treated with Novalis linear accelerator SRS. All patients were treated with a single-fraction dose of 11–20 Gy (median 14 Gy). The median tumor volume was 3.32 cm3 (range 0.24–51.7 cm3).
RESULTS
The median follow-up was 52 months (range 12–178 months). The actuarial local tumor control rates at 2, 5, and 10 years after SRS were 99.0%, 96.7%, and 86.3%, respectively. Twenty-seven (11.9%) patients developed new or worsened post-SRS PTE, with a median onset time of 5.2 months (range 1.2–50 months). Only 2 patients developed post-SRS PTE after 24 months. The authors evaluated factors related to new-onset or worsened PTE after SRS. In univariate analysis, initial tumor volume > 10 cm3 (p = 0.03), total marginal dose > 14 Gy (p < 0.001), preexisting edema (p < 0.0001), tumor location (p < 0.001), parasagittal location (p < 0.0001), superior sagittal sinus (SSS) involvement (p < 0.0001), and SSS invasion (p < 0.015) were found to be significant risk factors. In multivariate analysis, total marginal dose > 14 Gy (HR 3.38, 95% CI 1.37–8.33, p = 0.008), preexisting SRS edema (HR 12.86, 95% CI 1.09–4.15, p < 0.0001), tumor location (HR 2.13, 95% CI 1.04–3.72, p = 0.027), parasagittal location (HR 8.84, 95% CI 1.48–52.76, p = 0.017), and SSS invasion (HR 0.34, 95% CI 0.13–0.89, p = 0.027) were significant risk factors. Twelve (5.3%) patients were symptomatic. Ten of 27 patients had complete resolution of neurological symptoms and edema improvement with steroid treatment. Steroid treatment failed in 2 patients, who subsequently required resection for PTE.
CONCLUSIONS
Radiosurgery is a safe and effective method of treating benign intracranial meningiomas according to long-term follow-up. We also identified total marginal dose > 14 Gy, preexisting PTE, parasagittal location, and SSS invasion as predictors of post-SRS PTE. Risk factors for post-SRS PTE should be considered in meningioma treatment.
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Affiliation(s)
- Sheng-Han Huang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan
| | - Chun-Chieh Wang
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan; and
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan
| | - Hsien-Chih Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, Keelung, Taiwan
| | - Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan
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21
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Albano L, Deng H, Wei Z, Vodovotz L, Niranjan A, Lunsford LD. The longitudinal volumetric response of vestibular schwannomas after Gamma Knife radiosurgery. J Neurosurg 2022; 138:1273-1280. [PMID: 36087328 DOI: 10.3171/2022.7.jns22812] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is an effective treatment for vestibular schwannomas (VSs) and has been used in > 100,000 cases worldwide. In the present study the authors sought to define the serial volumetric tumor response of Koos grade I-IV VS after radiosurgery. METHODS A total of 201 consecutive VS patients underwent GKRS at a single institution between 2015 and 2019. All patients had a minimum follow-up of 18 months and at least 2 interval postprocedure MRI scans. The contrast-enhanced tumor volumes were contoured manually and compared between pre- and post-GKRS imaging. The percentages of tumor volume change at 18 months (short-term follow-up) and up to 5 years after GKRS (long-term follow-up) were compared with the baseline tumor volume. An increase of 20% was considered a significant increase of tumor volume. Trends of tumor volume over time were assessed with linear models using time as a continuous variable. A test for linear trend was evaluated according to the initial Koos tumor classification. RESULTS Koos grade II VS was the most frequently occurring tumor (n = 74, 36.8%), followed by grade III (n = 57, 28.4%), grade I (n = 41, 20.4%), and grade IV (n = 29, 14.4%). The mean tumor volume at the time of GKRS was 2.12 ± 2.82 cm3 (range 0.12-18.77 cm3) and the median margin dose was 12 Gy. Short-term follow-up revealed that tumor volumes transiently increased in 34.2% and 28.4% of patients at 6 and 18 months, respectively, regardless of Koos grade. Linear regression analysis of Koos grade II, III, and IV tumors showed a significant longitudinal volume decrease on long-term follow-up. At last follow-up (median 30 months, range 18-54 months), 19 patients (9.4%) showed a persistent increase of tumor volume. Five patients received additional management after GKRS. CONCLUSIONS Although selected VS patients demonstrate an early and measurable transient volumetric increase after GKRS, > 90% have stable or reduced tumor volumes over an observed period of up to 5 years. Volumetric regression is most pronounced in Koos grade II, III, and IV tumors and may not be fully detectable until 3 years after GKRS.
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Affiliation(s)
- Luigi Albano
- 1Department of Neurological Surgery and.,2Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hansen Deng
- 1Department of Neurological Surgery and.,2Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 1Department of Neurological Surgery and.,2Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lena Vodovotz
- 1Department of Neurological Surgery and.,2Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- 1Department of Neurological Surgery and.,2Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 1Department of Neurological Surgery and.,2Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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22
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Inoue T, Goto Y, Shima A, Hirai H, Shitara S, Suzuki F, Matsuda M. Effect of high-dose delivery on the attachment of meningiomas in Gamma Knife surgery: a retrospective study. Acta Neurochir (Wien) 2022; 164:2465-2471. [PMID: 35869331 DOI: 10.1007/s00701-022-05291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/18/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Meningiomas have vascular supply from the tumor attachment on the dura mater. Gamma Knife radiosurgery (GKS) is known to have a vascular obliterating effect. This study aims to determine the benefits of high-dose irradiation to the tumor attachment compared to conventional dose planning in the long-term control of tumor growth with GKS. METHODS Two different dose plannings were retrospectively compared in 75 patients with meningioma treated with GKS as a primary treatment. Forty-three patients were irradiated over 20 Gy to the tumor attachment. The remaining 32 patients were treated with conventional-dose planning. Tumor growth control, reduction of enhancement on the gadolinium-enhanced magnetic resonance imaging (MRI), and neurological status were retrospectively assessed. RESULTS The maximum dose on the tumor attachment was significantly higher in the high-dose group (23 Gy) than in the conventional group (16 Gy). The tumor margin was irradiated with the median of the 50% isodose line in both groups. The prescription doses resulted in 14 Gy and 12 Gy, respectively. The tumor control rate achieved 91% in both groups during the median follow-up period of 54 months. A decrease of enhancement on follow-up MRI was noted in one patient in each group. Kaplan-Meier analysis revealed no statistical difference in the progression-free survival between the two groups. The number of patients with improved neurological status showed no statistical difference. CONCLUSIONS No obvious benefit of high-dose irradiation to the tumor attachment and margin was found in tumor control and neurological status in the long term.
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Affiliation(s)
- Takuro Inoue
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan.
| | - Yukihiro Goto
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Ayako Shima
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Hisao Hirai
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Satoshi Shitara
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Fumio Suzuki
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Masayuki Matsuda
- Department of Neurosurgery, Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
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23
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Chiou GY, Chiang CL, Yang HC, Shen CI, Wu HM, Chen YW, Chen CJ, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Combined stereotactic radiosurgery and tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone for the treatment of non-small cell lung cancer patients with brain metastases. J Neurosurg 2022; 137:563-570. [PMID: 34920439 DOI: 10.3171/2021.9.jns211373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Whether combined radiation and tyrosine kinase inhibitor (TKI) therapy in non-small cell lung cancer (NSCLC) patients with brain metastases (BMs) and epidermal growth factor receptor (EGFR) mutations confers additional benefits over TKI therapy alone remains a matter of debate. The goal of this study was to compare outcomes between combined TKI therapy with stereotactic radiosurgery (SRS) versus TKI therapy alone in NSCLC patients with BMs and EGFR mutations. METHODS Consecutive cases of NSCLC patients with EGFR mutations and BMs treated with TKIs were selected for inclusion in this study. Patients were categorized into two groups based on SRS: TKI therapy alone (group I) and combined SRS and TKI therapy (group II). Patients who had SRS or TKI as salvage therapy and those with prior radiation treatment for BMs were excluded. Tumor control (< 10% increase in tumor volume) and overall survival (OS) rates were compared using Kaplan-Meier analyses. Independent predictors of tumor control and OS were identified using multivariable Cox regression analyses. RESULTS The study cohort comprised 280 patients (n = 90 in group I and n = 190 in group II). Cumulative tumor control rates were higher in group II than in group I (79.8% vs 31.2% at 36 months, p < 0.0001). Cumulative OS rates were comparable between groups I and II (43.8% vs 59.4% at 36 months, p = 0.3203). Independent predictors of tumor control were older age (p < 0.01, HR 1.03), fewer BMs (p < 0.01, HR 1.09), lack of extracranial metastasis (p < 0.02, HR 0.70), and combined SRS and TKI therapy (p < 0.01, HR 0.25). Independent predictors of OS were fewer BMs (p < 0.01, HR 1.04) and a higher Karnofsky Performance Status score (p < 0.01, HR 0.97). CONCLUSIONS Although the OS rate did not differ between TKI therapy with and without SRS, the addition of SRS to TKI therapy resulted in improvement of intracranial tumor control. The lack of effect on survival rate with the addition of SRS may be attributable to extracranial disease progression. The addition of SRS to TKI therapy is recommended for intracranial disease control in NSCLC patients with BMs and EGFR mutations. Potential benefits may include prevention of neurological deficits and seizures. Future prospective studies may help clarify the clinical outcome benefits of SRS in these patients.
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Affiliation(s)
- Guan-Ying Chiou
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
| | - Chi-Lu Chiang
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chia-I Shen
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Hsiu-Mei Wu
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
| | - Ching-Jen Chen
- 9Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Yung-Hung Luo
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Yong-Sin Hu
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chung-Jung Lin
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Cheng-Ying Shiau
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Cancer Center, Taipei Veterans General Hospital, Taipei
| | - Wan-Yuo Guo
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Brain Research Center, National Yang Ming Chiao Tung University, Taipei
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Tumor control and radiobiological fingerprint after Gamma Knife radiosurgery for posterior fossa meningiomas: A series of 46 consecutive cases. J Clin Neurosci 2022; 100:196-203. [PMID: 35489255 DOI: 10.1016/j.jocn.2022.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/16/2022] [Accepted: 04/24/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Gamma Knife radiosurgery (GKR) can be a valuable treatment option for posterior cranial fossa meningiomas (PCFM). We retrospectively analyzed outcomes of GKR for PCFM. METHODS Were included forty-six patients with 47 PCFM. Primary endpoint was tumor control. Secondary endpoint was clinical improvement. Biologically effective dose (BED) was evaluated in relationship to primary and secondary outcomes. Mean marginal dose was 12.4 Gy (median 12, 12-14). Mean BED was 63.6 Gy (median 65, 49.1-88.3). Mean target volume (TV) was 2.21 cc (range 0.3-8.9 cc). RESULTS Overall tumor control rate was 93.6% (44/47) after mean follow-up of 47.8 months ± 28.46 months (median 45.5, range 6-108). Radiological progression-free survival at 5 years was 94%. Higher pretherapeutic TVs were predictive for higher likelihood of tumor progression (Odds ratio, OR 1.448, 95% confidence interval - CI 1.001-2.093, p = 0.049). At last clinical follow-up, 28 patients (71.8%) remained stable, 10 (25.6%) improved and 1 patient (2.6%) worsened. Using logistic regression, the relationship between BED and clinical improvement was assessed (OR 0.903, standard error 0.59, coefficient 0.79-1.027, CI -0.10; 0.01; p = 0.14). The highest probability of clinical improvement corresponded to a range of BED values between 56 and 61 Gy. CONCLUSION Primary GKR for PCFM is safe and effective. Higher pretherapeutic TV was predictor of volumetric progression. Highest probability of clinical improvement might correspond to a range of BED values between 56 and 61 Gy, although this was not statistically significant. The importance of BED should be further validated in larger cohorts, other anatomical locations and other pathologies.
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Fouard O, Daisne JF, Wanet M, Regnier M, Gustin T. Long-term volumetric analysis of vestibular schwannomas following stereotactic radiotherapy: Practical implications for follow-up. Clin Transl Radiat Oncol 2022; 33:1-6. [PMID: 34977365 PMCID: PMC8688865 DOI: 10.1016/j.ctro.2021.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022] Open
Abstract
Pseudoprogression may be a late phenomenon after radiosurgery. Loss of central contrast enhancement is not predictive of tumor control. No decision of salvage therapy should be made until the 6th year post-treatment.
Background and purpose Transient tumor swelling is a well-known phenomenon following radiotherapy for vestibular schwannomas (VS). We analyzed the long-term volumetric changes of VS after LINAC radiosurgery, in order to determine a time interval during which a true tumor progression can be distinguished from a pseudoprogression. Methods Among 63 patients with VS treated by one fraction or fractionated radiotherapy, we selected 52 of them who had a minimal follow-up of 5 years. Maximal axial diameter and three-dimensional tumor volume were measured on each MRI scan. Volume changes were interpreted using different error margins ranging from 10 to 20%. Patients were categorized according to the tumor evolution pattern over time. Results Median follow-up was 83 months. One tumor (1.9%) remained stable and 26.9% had continuous shrinkage. Applying an error margin of 13%, a transient tumor enlargement was observed in 63.5% of patients, with a first peak at 6–12 months and a late peak at 3–4 years. A true progression was suspected in 4 (7.7%) patients, tumor regrowth starting after the 3rd or 4th year post-treatment. Only one patient required salvage radiotherapy. Conclusion Transient swelling of VS following radiotherapy is generally an early phenomenon but may occur late. In the first 5 years, a true tumor progression cannot be differentiated from a pseudoprogression. A significant tumor expansion observed on 3 sequential MRI scans after the 3rd year may be suggestive of treatment failure. Long-term follow-up is therefore mandatory and no decision of salvage treatment should be made until the 6th year.
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Affiliation(s)
- O Fouard
- Neurosurgery Department, CHU UCL Namur site Godinne, Université Catholique de Louvain, Yvoir, Belgium
| | - J F Daisne
- Radiation Oncology Department, CHU UCL Namur Site Sainte-Elisabeth, Université Catholique de Louvain, Namur, Belgium.,Radiation Oncology Department, University Hospitals Leuven, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Oncology and Leuven Cancer Institute, Katholieke Universiteit Leuven, Leuven, Belgium
| | - M Wanet
- Radiation Oncology Department, CHU UCL Namur Site Sainte-Elisabeth, Université Catholique de Louvain, Namur, Belgium
| | - M Regnier
- Scientific Support Unit, CHU UCL Namur, Université catholique de Louvain, Namur, Belgium
| | - T Gustin
- Neurosurgery Department, CHU UCL Namur site Godinne, Université Catholique de Louvain, Yvoir, Belgium
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Pomeraniec IJ, Xu Z, Lee CC, Yang HC, Chytka T, Liscak R, Martinez-Alvarez R, Martinez-Moreno N, Attuati L, Picozzi P, Kondziolka D, Mureb M, Bernstein K, Mathieu D, Maillet M, Ogino A, Long H, Kano H, Lunsford LD, Zacharia BE, Mau C, Tuanquin LC, Cifarelli C, Arsanious D, Hack J, Warnick RE, Strickland BA, Zada G, Chang EL, Speckter H, Patel S, Ding D, Sheehan D, Sheehan K, Kvint S, Buch LY, Haber AR, Shteinhart J, Vance ML, Sheehan JP. Dose to neuroanatomical structures surrounding pituitary adenomas and the effect of stereotactic radiosurgery on neuroendocrine function: an international multicenter study. J Neurosurg 2021; 136:813-821. [PMID: 34560630 DOI: 10.3171/2021.3.jns203812] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) provides a safe and effective therapeutic modality for patients with pituitary adenomas. The mechanism of delayed endocrine deficits based on targeted radiation to the hypothalamic-pituitary axis remains unclear. Radiation to normal neuroendocrine structures likely plays a role in delayed hypopituitarism after SRS. In this multicenter study by the International Radiosurgery Research Foundation (IRRF), the authors aimed to evaluate radiation tolerance of structures surrounding pituitary adenomas and identify predictors of delayed hypopituitarism after SRS for these tumors. METHODS This is a retrospective review of patients with pituitary adenomas who underwent single-fraction SRS from 1997 to 2019 at 16 institutions within the IRRF. Dosimetric point measurements of 14 predefined neuroanatomical structures along the hypothalamus, pituitary stalk, and normal pituitary gland were made. Statistical analyses were performed to determine the impact of doses to critical structures on clinical, radiographic, and endocrine outcomes. RESULTS The study cohort comprised 521 pituitary adenomas treated with SRS. Tumor control was achieved in 93.9% of patients over a median follow-up period of 60.1 months, and 22.5% of patients developed new loss of pituitary function with a median treatment volume of 3.2 cm3. Median maximal radiosurgical doses to the hypothalamus, pituitary stalk, and normal pituitary gland were 1.4, 7.2, and 11.3 Gy, respectively. Nonfunctioning adenoma status, younger age, higher margin dose, and higher doses to the pituitary stalk and normal pituitary gland were independent predictors of new or worsening hypopituitarism. Neither the dose to the hypothalamus nor the ratio between doses to the pituitary stalk and gland were significant predictors. The threshold of the median dose to the pituitary stalk for new endocrinopathy was 10.7 Gy in a single fraction (OR 1.77, 95% CI 1.17-2.68, p = 0.006). CONCLUSIONS SRS for the treatment of pituitary adenomas affords a high tumor control rate with an acceptable risk of new or worsening endocrinopathy. This evaluation of point dosimetry to adjacent neuroanatomical structures revealed that doses to the pituitary stalk, with a threshold of 10.7 Gy, and doses to the normal gland significantly increased the risk of post-SRS hypopituitarism. In patients with preserved pre-SRS neuroendocrine function, limiting the dose to the pituitary stalk and gland while still delivering an optimal dose to the tumor appears prudent.
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Affiliation(s)
| | | | - Cheng-Chia Lee
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Huai-Che Yang
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Tomas Chytka
- 5Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- 5Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Luca Attuati
- 7Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Piero Picozzi
- 7Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | | | | | | | | | - Michel Maillet
- 11Endocrinology, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - Akiyoshi Ogino
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hao Long
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Leonard C Tuanquin
- 14Radiation Oncology, Penn State Health-Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Joshua Hack
- 16Radiation Oncology, West Virginia University Medical Center, Morgantown, West Virginia
| | - Ronald E Warnick
- 17Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio
| | | | | | - Eric L Chang
- 19Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Herwin Speckter
- 20Centro Gamma Knife Dominicano and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Samir Patel
- 21Division of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Dale Ding
- 22Department of Neurosurgery, University of Louisville Hospital, Louisville, Kentucky; and
| | | | | | - Svetlana Kvint
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Love Y Buch
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander R Haber
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob Shteinhart
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Lee Vance
- Departments of1Neurosurgery.,2Radiation Oncology, and.,3Medicine and Endocrinology, University of Virginia Health Science Center, Charlottesville, Virginia
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Long-term outcome in meningiomas involving the major dural sinuses with combined therapy of subtotal resection and early postoperative gamma knife radiosurgery. Acta Neurochir (Wien) 2021; 163:1677-1685. [PMID: 33608765 DOI: 10.1007/s00701-021-04766-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 02/10/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Total resection of meningiomas involving the major dural sinuses (MIMDS) is still challenging for neurosurgeons. Gamma knife radiosurgery (GKRS) was shown to have a high probability of tumor control. The current study evaluated the clinical outcomes of patients who underwent subtotal resection alone or in combination with postoperative GKRS for the treatment of WHO grade I MIMDS. METHODS From January 2006 to December 2016, 204 patients with MIMDS underwent Simpson IV subtotal resection in Wuhan Union Hospital. In 151 patients, no additional treatment was performed, while the tumor remnant was treated with GKRS in 53 patients. All patients were monitored with regular MR follow-ups. We retrospectively reviewed the clinical data, radiological characteristics, and outcomes of these 204 patients. Progression-free survival (PFS) was determined by Kaplan-Meier analysis. Related factors were determined by univariate Cox regression analyses. RESULTS The mean follow-up period was 75.5 months. The tumor recurrence/progression rates were 13.9% in the microsurgery group and 3.8% in the combined therapy group (p = 0.045). The 5- and 10- year progression-free survival (PFS) rates were 92.3 and 80.7%, respectively, in the microsurgery group and 100.0 and 88.5% in the combined therapy group. Treatment approach was found to be an independent prognostic factor for tumor recurrence/progression in the univariable analyses (p=0.04). CONCLUSIONS Compared with microsurgery alone, targeted Simpson grade IV resection combined with early gamma knife treatment resulted in longer progression-free survival without increased complications for WHO grade I MIMDS.
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Bunevicius A, Lavezzo K, Shabo L, McClure J, Sheehan JP. Quality-of-life trajectories after stereotactic radiosurgery for brain metastases. J Neurosurg 2021; 134:1791-1799. [PMID: 32650308 DOI: 10.3171/2020.4.jns20788] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Quality of life (QOL) is an important endpoint measure of cancer treatment. The authors' goal was to evaluate QOL trajectories and prognostic value in cancer patients treated with stereotactic radiosurgery (SRS) for brain metastases. METHODS Patients who underwent Gamma Knife radiosurgery (GKRS) between January 2016 and November 2019 were prospectively evaluated for QOL using the EQ-5D-3L questionnaire before SRS and at follow-up visits. Only patients who had pre-SRS and at least 1 post-SRS QOL assessment were considered. RESULTS Fifty-four cancer patients underwent 109 GKRS procedures. The first post-SRS visit was at a median of 2.59 months (range 0.13-21.08 months), and the last post-SRS visit was at 14.72 months (range 2.52-45.21 months) after SRS. There was no statistically significant change in the EQ-5D index score (p = 0.539) at the first compared with last post-SRS visit. The proportion of patients reporting some problems on the EQ-5D dimension of self-care increased during the course of follow-up from 9% (pre-SRS visit) to 18% (last post-SRS visit; p = 0.03). The proportion of patients reporting problems on the EQ-5D dimensions of mobility, usual activities, pain/discomfort, and anxiety/depression remained stable during the course of follow-up (p ≥ 0.106). After adjusting for clinical variables, a higher recursive partitioning analysis (RPA) class (i.e., worse prognostic category) was independently associated with greater odds for EQ-5D index score deterioration (p = 0.050). Upfront whole-brain radiation therapy predicted deterioration of the EQ-5D self-care (p = 0.03) and usual activities (p = 0.024) dimensions, while a greater number of lesions predicted deterioration of the EQ-5D anxiety/depression dimension (p = 0.008). A lower pre-SRS EQ-5D index was associated with shorter survival independently from clinical and demographic variables (OR 18.956, 95% CI 2.793-128.64; p = 0.003). CONCLUSIONS QOL is largely preserved in brain metastasis patients treated with SRS. Higher RPA class, upfront whole-brain radiation therapy, and greater intracranial disease burden are independent predictors of post-SRS QOL deterioration. Worse pre-SRS QOL predicts shorter survival. Assessment of QOL is recommended in brain metastasis patients managed with SRS.
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Affiliation(s)
- Adomas Bunevicius
- 1Department of Neurological Surgery, University of Virginia Health System; and
| | - Karen Lavezzo
- 1Department of Neurological Surgery, University of Virginia Health System; and
| | - Leah Shabo
- 2School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Jesse McClure
- 2School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System; and
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Jeon C, Cho KR, Choi JW, Kong DS, Seol HJ, Nam DH, Lee JI. Gamma Knife radiosurgery as a primary treatment for central neurocytoma. J Neurosurg 2021. [DOI: 10.3171/2020.4.jns20350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
This study was performed to evaluate the role of Gamma Knife radiosurgery (GKRS) as a primary treatment for central neurocytomas (CNs).
METHODS
The authors retrospectively assessed the treatment outcomes of patients who had undergone primary treatment with GKRS for CNs in the period between December 2001 and December 2018. The diagnosis of CN was based on findings on neuroimaging studies. The electronic medical records were retrospectively reviewed for additional relevant preoperative data, and clinical follow-up data had been obtained during office evaluations of the treated patients. All radiographic data were reviewed by a dedicated neuroradiologist.
RESULTS
Fourteen patients were treated with GKRS as a primary treatment for CNs in the study period. Seven patients (50.0%) were asymptomatic at initial presentation, and 7 (50.0%) presented with headache. Ten patients (71.4%) were treated with GKRS after the diagnosis of CN based on characteristic MRI findings. Four patients (28.6%) initially underwent either stereotactic or endoscopic biopsy before GKRS. The median tumor volume was 3.9 cm3 (range 0.46–18.1 cm3). The median prescription dose delivered to the tumor margin was 15 Gy (range 5.5–18 Gy). The median maximum dose was 30 Gy (range 11–36 Gy). Two patients were treated with fractionated GKRS, one with a prescription dose of 21 Gy in 3 fractions and another with a dose of 22 Gy in 4 fractions. Control of tumor growth was achieved in all 14 patients. The median volume reduction was 26.4% (range 0%–78.3%). Transient adverse radiation effects were observed in 2 patients but resolved with improvement in symptoms. No recurrences were revealed during the follow-up period, which was a median of 25 months (range 12–89 months).
CONCLUSIONS
Primary GKRS for CNs resulted in excellent tumor control rates without recurrences. These results suggest that GKRS may be a viable treatment option for patients with small- to medium-sized or incidental CNs.
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Gamma Knife radiosurgery for the treatment of central neurocytoma: a single-institution experience of 25 patients. Neurosurg Rev 2021; 44:3427-3435. [PMID: 33733378 DOI: 10.1007/s10143-021-01518-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
Central neurocytomas (CNs) are extremely rare tumors that account for 0.1-0.5% of all intracranial neoplasms. Recently, Gamma Knife radiosurgery (GKRS) has become a treatment option in patients with CN. We aimed to evaluate the efficacy and safety of GKRS in 25 CN patients and review the results along with relevant literature. GKRS patient database was searched, and 25 patients who underwent GKRS for CN between 2009 and 2018, were evaluated retrospectively. The study cohort included 15 female and ten male patients with a median age of 32 years (range, 5-60). The most common presenting symptom was headache (88%). The neurological examination was unremarkable in all patients, except for one patient with decreased vision. Twenty patients (80%) had a history of surgical resection. Most of the tumors (92%) were located in the ventricles, and the median tumor volume was 4.8 cm3 (range, 0.8-28.1). The median marginal dose was 14 Gy (range, 12-15) to a median isodose of 50% (range, 40-50). Following a median follow-up of 80 months (range, 36-138), local tumor control was achieved in 100% of patients. Distant recurrence was observed in one patient (4%). No adverse radiation effect was observed. Regarding non-specific post-GKRS symptoms, one patient experienced a prolonged headache, and one epileptic patient experienced a brief partial seizure. In our patient cohort, GKRS yielded favorable local tumor control (100%) during a median follow-up of 6.6 years. Our series demonstrates that GKRS is an effective and safe treatment option for patients with primary or residual CNs.
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Impact of EGFR mutation on outcomes following SRS for brain metastases in non-small cell lung cancer. Lung Cancer 2021; 155:34-39. [PMID: 33721614 DOI: 10.1016/j.lungcan.2021.02.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/26/2020] [Accepted: 02/28/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Patients with EGFR-mutated (EGFRm) non-small cell lung cancer (NSCLC) are at particularly high risk of developing brain metastases (BrM). In addition to EGFR targeting tyrosine kinase inhibitors (TKI), radiosurgery (SRS) has an important role in the management of EGFRm BrM. However, data specific to the response and toxicity of EGFRm BrM to SRS are sparse. We evaluated the incidence of local failure (LF) and toxicity of EGFRm and EGFR-wild-type (EGFRwt) BrM treated with SRS. METHODS We analyzed a prospective registry of BrM patients treated at our centre between 2008 and 2017 and identified EGFRm and EGFRwt NSCLC patients treated with SRS ± systemic therapy for BrM. Incidences of local failure (LF) and radionecrosis (RN) were determined, and Cox regression was performed for univariate and multivariate analyses (MVAs). RESULTS We analyzed data from 218 patients (615 lesions - 225 EGFRm and 390 EGFRwt). Median imaging follow-up per patient was 14.5 months (0.5-96.3). Prior to or concomitant with SRS, 62 % of EGFRm patients received TKI and 93 % received TKI post SRS. The 24-month incidence of LF was 6% and 16 % for EGFRm BrM and EGFRwt, respectively (0.43(0.19-0.95); p = 0.037). The 24-month incidence of RN was 4% and 6% for EGFRm and EGFRwt BrM, respectively (0.8(0.32-1.98) p = 0.63). On MVA, BrM size and prescription dose (PD) significantly correlated with a higher risk of LF and BrM size correlated with a higher risk of RN. CONCLUSION We observed excellent rates of response and toxicity following SRS in EGFRm compared to EGFRwt NSCLC, suggesting that EGFRm BrM have a favourable risk benefit ratio compared to EGFRwt NSCLC.
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Galarza M, Etus V, Sosa F, Argañaraz R, Mantese B, Gazzeri R, Montoya CG, de la Rosa P, Guerrero AL, Chaban G, Giménez Á, Amigó JM. Flow ventricular catheters for shunted hydrocephalus: initial clinical results. Childs Nerv Syst 2021; 37:903-911. [PMID: 33123821 DOI: 10.1007/s00381-020-04941-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The non-homogenous flow of the cerebrospinal fluid within the ventricular catheter is one of the causative factors in shunt obstructions during the treatment of hydrocephalus. Previously, we studied the flow in ventricular catheters under the steady and pulsatile boundary conditions by means of computational fluid dynamics (CFD) in three-dimensional paradigms. Subsequently, several catheter designs with homogeneous flow patterns were developed out of which one prototype was chosen after a validation study. OBJECTIVE To test the effectiveness of the flow ventricular catheter in a prospective, multicenter, comparative study. METHODS Eligible centers were three pediatric hospitals: two with sole adult practice and one a mixed pediatric-adult. Standard silicone material was used to develop a parametric catheter model with homogenous flow characteristics. The flow catheters were inserted in pediatric (n = 30) and adult (n = 10) patients with all types of hydrocephalus. Simultaneously, regular ventricular catheters were inserted in another 43 control patients in the participating centers. Catheter positioning was standardized according to the Schaumann and Thomale classification. RESULTS All ventricular catheters had a cephalad grade I or II positioning, and caudally, its extension had a peritoneal location. Programmable valves were utilized in 70% and antisiphon devices in 20% of the cases. Regular differential pressure valves were utilized in the remaining. No case of flow catheter obstruction was identified during a mean follow-up period of 2 years at the time of this writing. There were four catheter obstructions in the control cohort, all pediatric cases, during the first year. Shunt infections occurred in two cases in the control group, while there was one recurrent case of adult ventriculitis in the flow catheter group. CONCLUSIONS This prototype model represents the next generation of ventricular catheters with a homogeneous flow pattern. The flow catheter can be inserted safely in hydrocephalic patients, and this preliminary prospective comparative study showed a possible obstruction-free functionality.
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Affiliation(s)
- Marcelo Galarza
- Regional Service of Neurosurgery, School of Medicine, Hospital Universitario Virgen de la Arrixaca, University of Murcia, El Palmar, E-30120, Murcia, Spain.
| | - Volkan Etus
- Department of Neurosurgery, Kocaeli University Hospital, Kocaeli, Turkey
| | - Fidel Sosa
- Department of Neurosurgery, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Romina Argañaraz
- Department of Neurosurgery, Hospital Nacional de Pediatría J. Garrahan, Buenos Aires, Argentina
| | - Beatriz Mantese
- Department of Neurosurgery, Hospital Nacional de Pediatría J. Garrahan, Buenos Aires, Argentina
| | - Roberto Gazzeri
- Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy
| | | | - Pedro de la Rosa
- Regional Service of Neurosurgery, School of Medicine, Hospital Universitario Virgen de la Arrixaca, University of Murcia, El Palmar, E-30120, Murcia, Spain
| | - Antonio López Guerrero
- Regional Service of Neurosurgery, School of Medicine, Hospital Universitario Virgen de la Arrixaca, University of Murcia, El Palmar, E-30120, Murcia, Spain
| | - Gerald Chaban
- Unit of Neurosurgery, University Hospital of Torrevieja, Torrevieja, Spain
| | - Ángel Giménez
- Operations Research Center, University Miguel Hernández de Elche, Elche, Spain
| | - José María Amigó
- Operations Research Center, University Miguel Hernández de Elche, Elche, Spain
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Lee CC, Lee WK, Wu CC, Lu CF, Yang HC, Chen YW, Chung WY, Hu YS, Wu HM, Wu YT, Guo WY. Applying artificial intelligence to longitudinal imaging analysis of vestibular schwannoma following radiosurgery. Sci Rep 2021; 11:3106. [PMID: 33542422 PMCID: PMC7862268 DOI: 10.1038/s41598-021-82665-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Artificial intelligence (AI) has been applied with considerable success in the fields of radiology, pathology, and neurosurgery. It is expected that AI will soon be used to optimize strategies for the clinical management of patients based on intensive imaging follow-up. Our objective in this study was to establish an algorithm by which to automate the volumetric measurement of vestibular schwannoma (VS) using a series of parametric MR images following radiosurgery. Based on a sample of 861 consecutive patients who underwent Gamma Knife radiosurgery (GKRS) between 1993 and 2008, the proposed end-to-end deep-learning scheme with automated pre-processing pipeline was applied to a series of 1290 MR examinations (T1W+C, and T2W parametric MR images). All of which were performed under consistent imaging acquisition protocols. The relative volume difference (RVD) between AI-based volumetric measurements and clinical measurements performed by expert radiologists were + 1.74%, - 0.31%, - 0.44%, - 0.19%, - 0.01%, and + 0.26% at each follow-up time point, regardless of the state of the tumor (progressed, pseudo-progressed, or regressed). This study outlines an approach to the evaluation of treatment responses via novel volumetric measurement algorithm, and can be used longitudinally following GKRS for VS. The proposed deep learning AI scheme is applicable to longitudinal follow-up assessments following a variety of therapeutic interventions.
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Affiliation(s)
- Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Kai Lee
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Chun Wu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Te Wu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan.
- Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan.
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Bunevicius A, Sheehan D, Lee Vance M, Schlesinger D, Sheehan JP. Outcomes of Cushing's disease following Gamma Knife radiosurgery: effect of a center's growing experience and era of treatment. J Neurosurg 2021; 134:547-554. [PMID: 32005023 DOI: 10.3171/2019.12.jns192743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is used for the management of residual or recurrent Cushing's disease (CD). Increasing experience and technological advancements of Gamma Knife radiosurgery (GKRS) systems can impact the outcomes of CD patients. The authors evaluated the association of their center's growing experience and the era in which GKRS was performed with treatment success and adverse events in patients with CD. METHODS The authors studied consecutive patients with CD treated with GKRS at the University of Virginia since installation of the first Gamma Knife system in March 1989 through August 2019. They compared endocrine remission and complication rates between patients treated before 2000 (early cohort) and those who were treated in 2000 and later (contemporary cohort). RESULTS One hundred thirty-four patients with CD underwent GKRS during the study period: 55 patients (41%) comprised the early cohort, and 79 patients (59%) comprised the contemporary cohort. The contemporary cohort, compared with the early cohort, had a significantly greater treatment volume, radiation prescription dose, maximal dose to the optic chiasm, and number of isocenters, and they more often had cavernous sinus involvement. Endocrine remission rates were higher in the contemporary cohort when compared with the early cohort (82% vs 66%, respectively; p = 0.01). In a Cox regression analysis adjusted for demographic, clinical, and SRS characteristics, the contemporary GKRS cohort had a higher probability of endocrine remission than the early cohort (HR 1.987, 95% CI 1.234-3.199; p = 0.005). The tumor control rate, incidence of cranial nerve neuropathy, and new anterior pituitary deficiency were similar between the two groups. CONCLUSIONS Technological advancements over the years and growing center experience were important factors for improved endocrine remission rates in patients with CD. Technological aspects and results of contemporary Gamma Knife systems should be considered when counseling patients, planning treatment, and reporting treatment results. Studies exploring the learning curve for GKRS are warranted.
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Affiliation(s)
| | | | - Mary Lee Vance
- Departments of1Neurological Surgery and
- 2Medicine, University of Virginia Health System, Charlottesville, Virginia
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Akyoldaş G, Samancı Y, Yılmaz M, Şengöz M, Peker S. Long-term results of gamma knife radiosurgery for foramen magnum meningiomas. Neurosurg Rev 2020; 44:2667-2673. [PMID: 33244665 DOI: 10.1007/s10143-020-01446-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 11/28/2022]
Abstract
Outcomes of 37 patients of foramen magnum meningioma (FMM) were evaluated, and the related literature was reviewed to determine the efficacy of Gamma Knife radiosurgery (GKRS) for treating patients with FMM. We present the largest series reported from a single institution with the longest follow-up to date. The database of patients who underwent GKRS for FMM between 2007 and 2019 was evaluated retrospectively. A total of 37 patients with radiological and pathological features consistent with FMM were included in this series. Thirty-three patients were female, and 4 were male. The median age was 58 years (range, 23-74 years). The most common symptom at diagnosis was headache (64.9%). Twelve patients had a history of microsurgical resection. The median duration from the initial onset of symptoms to GKRS was 12 months (range 1-140 months). Among the 37 tumors, eight (21.6%) were located ventrally, 24 (64.9%) laterally, and five (13.5%) dorsally. The median target volume was 3.30 cm3 (range, 0.6-17.6 cm3). Thirty-five patients (95%) were treated with single fraction GKRS, and two patients (5%) were treated with hypofractionated GKRS. The median clinical follow-up was 80 months (range, 18-151 months), while the median radiological follow-up was 84 months (range, 18-144 months). At the last clinical follow-up after GKRS, 27 patients (73%) had improved symptoms, and none had worsened pre-GKRS symptoms. At the last radiological follow-up after GKRS, 23 tumors (62.2%) remained stable, 13 (35.1%) decreased in size, and 1 (2.7%) increased in size. Tumor control, including stable and regressed tumors, was achieved in 97.3% of patients. Our cohort demonstrates that GKRS is an effective and safe treatment for patients with either primary or recurrent/residual FMM.
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Affiliation(s)
- Göktuğ Akyoldaş
- Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey.
| | - Yavuz Samancı
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Meltem Yılmaz
- Medical Biotechnology, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Meriç Şengöz
- Department of Radiation Oncology, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Selçuk Peker
- Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
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Taylor DG, Janssen A, Ding D, Xu Z, Mehta GU, Liscak R, Kano H, Kosak M, Martinez-Moreno N, Hobbs L, Chen CJ, Grills IS, Mathieu D, Lunsford LD, Vance ML, Sheehan JP. Whole Sella vs Targeted Stereotactic Radiosurgery for Acromegaly: A Multicenter Matched Cohort Study. Neurosurgery 2020; 86:656-664. [PMID: 31384920 DOI: 10.1093/neuros/nyz245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/11/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Targeted stereotactic radiosurgery (SRS) with sparing of the residual pituitary is the traditional radiosurgical method for pituitary adenomas. Whole-sella SRS is an alternative choice for radiologically indeterminate or large adenomas, the safety and efficacy of which has yet to be determined. OBJECTIVE To determine if whole-sella SRS in acromegaly would have comparable radiographic and biochemical control to targeted SRS. We performed a multicenter, retrospective matched cohort study to compare outcomes between groups. METHODS We conducted a retrospective review of acromegalic patients who underwent SRS from 1990 to 2016 at 10 centers participating in the International Radiosurgery Research Foundation. Whole-sella and targeted SRS patients were then matched in a 1:1 ratio. RESULTS A total of 128 patients were eligible for inclusion. Whole-sella patients had a higher pre-SRS random serum growth hormone, larger treatment volume, and higher maximum point dose to the optic apparatus. The rates of initial/durable endocrine remission, new loss of pituitary function, and new cranial neuropathy were similar between groups. Mortality and new visual deficit were higher in the whole-sella cohort, though not statistically significant. CONCLUSION There was no difference in biochemical remission or recurrence between treatment groups. Although not statistically significant, the higher rates of tumor regression and lower rates of mortality and new visual deficit may suggest consideration of targeted SRS over whole-sella SRS in acromegaly treatment. Further research is needed to determine the association between visual deficits and mortality with whole-sella SRS.
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Affiliation(s)
- Davis G Taylor
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Andrew Janssen
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Zhiyuan Xu
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Gautam U Mehta
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mikulas Kosak
- First Faculty of Medicine, 3rd Department of Medicine, Charles University, Prague, Czech Republic
| | | | - Landon Hobbs
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - David Mathieu
- Centre de recherche du CHUS, Division of Neurosurgery, University of Sherbrooke, Sherbrooke, Canada
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Lee Vance
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia.,Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Implementation of a dedicated 1.5 T MR scanner for radiotherapy treatment planning featuring a novel high-channel coil setup for brain imaging in treatment position. Strahlenther Onkol 2020; 197:246-256. [PMID: 33103231 PMCID: PMC7892740 DOI: 10.1007/s00066-020-01703-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/29/2020] [Indexed: 12/17/2022]
Abstract
Purpose To share our experiences in implementing a dedicated magnetic resonance (MR) scanner for radiotherapy (RT) treatment planning using a novel coil setup for brain imaging in treatment position as well as to present developed core protocols with sequences specifically tuned for brain and prostate RT treatment planning. Materials and methods Our novel setup consists of two large 18-channel flexible coils and a specifically designed wooden mask holder mounted on a flat tabletop overlay, which allows patients to be measured in treatment position with mask immobilization. The signal-to-noise ratio (SNR) of this setup was compared to the vendor-provided flexible coil RT setup and the standard setup for diagnostic radiology. The occurrence of motion artifacts was quantified. To develop magnetic resonance imaging (MRI) protocols, we formulated site- and disease-specific clinical objectives. Results Our novel setup showed mean SNR of 163 ± 28 anteriorly, 104 ± 23 centrally, and 78 ± 14 posteriorly compared to 84 ± 8 and 102 ± 22 anteriorly, 68 ± 6 and 95 ± 20 centrally, and 56 ± 7 and 119 ± 23 posteriorly for the vendor-provided and diagnostic setup, respectively. All differences were significant (p > 0.05). Image quality of our novel setup was judged suitable for contouring by expert-based assessment. Motion artifacts were found in 8/60 patients in the diagnostic setup, whereas none were found for patients in the RT setup. Site-specific core protocols were designed to minimize distortions while optimizing tissue contrast and 3D resolution according to indication-specific objectives. Conclusion We present a novel setup for high-quality imaging in treatment position that allows use of several immobilization systems enabling MR-only workflows, which could reduce unnecessary dose and registration inaccuracies. Electronic supplementary material The online version of this article (10.1007/s00066-020-01703-y) contains supplementary material, which is available to authorized users.
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Li Y, Huang M, Liang S, Peng C, Li X, Zeng J, He Y, Li W, Deng Y, Yu J. Gamma Knife Radiosurgery (GKRS) for Patients with Prolactinomas: Long-Term Results From a Single-Center Experience. Med Sci Monit 2020; 26:e924884. [PMID: 32964894 PMCID: PMC7521071 DOI: 10.12659/msm.924884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The aim of this study was to review outcomes of gamma knife radiosurgery (GKRS) for prolactinoma and report our experience with it. Material/Methods We reviewed the patient database in our center and identified 24 patients with prolactinoma who underwent GKRS from 1993 to 2016. Complete endocrine, clinical, and radiological data were available on these individuals before and after GKRS. Results Data from 5 males and 19 females with a median age of 30.5 years (range, 18.1 to 51.1) were reviewed. The median follow-up was 109.3 months (range, 23.2–269.3). The median margin dose of GKRS was 15 Gy (range, 10.5 to 23.6). In total, prolactin (PRL) normalization after GKRS was achieved in 66.7% of patients. Endocrine remission (normal PRL levels after discontinuation of dopamine agonists) was achieved in 10 patients (41.7%), and endocrine control (normal PRL levels while taking dopamine agonists) was achieved in 6 patients (25.0%). All of the patients showed tumor control. New-onset hypopituitarism post-GKRS occurred in 4 patients (16.7%). No new visual dysfunction or cranial nerve dysfunction were observed after GKRS. Conclusions For treatment of prolactinomas, GKRS may provide relatively high rates of endocrine remission and tumor control, as well as a low rate of new-onset hypopituitarism. GKRS may be an effective and safe treatment for prolactinomas.
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Affiliation(s)
- Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Minyi Huang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Shunyao Liang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Chao Peng
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Xi Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jiamin Zeng
- Department of Pathology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yong He
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yinhui Deng
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jinxiu Yu
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
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Lee WJ, Cho KR, Choi JW, Kong DS, Seol HJ, Nam DH, Lee JI. Gamma Knife Radiosurgery as a Primary Treatment for Nonfunctioning Pituitary Adenoma Invading the Cavernous Sinus. Stereotact Funct Neurosurg 2020; 98:371-377. [PMID: 32937617 DOI: 10.1159/000508737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Surgical resection of nonfunctioning pituitary adenoma (NFPA) invading the cavernous sinus (CS) remains a challenging and significant factor associated with incomplete resection. The residual tumor in CS is usually treated with adjuvant stereotactic radiosurgery (SRS), but there is little information concerning SRS as an initial treatment for CS-invading NFPA. In this study, we investigated the tumor control rate and clinical outcomes of the patients who received primary gamma knife radiosurgery (GKRS) for CS-invading NFPA. METHODS This was a single-institute retrospective analysis of 11 patients. CS invasion of tumor was categorized using the modified Knosp grading system. The median tumor volume and maximal diameter were 1.6 cm3 (range 0.4-6.5) and 17.2 mm (range 11.6-23.3), respectively. The median clinical follow-up period was 48.5 months (range 16.4-177.8). The median prescription dose at tumor margin was 15 Gy (range 11-25) and median prescription isodose was 50% (range 45-50). The maximum radiation dose to optic chiasm and optic nerve were 7.2 Gy (range 3.4-9.2) and 7.5 Gy (range 4.5-11.5), respectively. RESULTS Tumor control was achieved in all patients. The median tumor volume and maximal diameter at last follow-up were 0.4 cm3 (range 0.1-2.3) and 11.4 mm (range 4.7-19.5), respectively. The median volume reduction rate was 52% (range 33-88). Six patients showed downgrading of modified Knosp grade after GKRS. No patients developed GKRS-related complications such as hypopituitarism or visual disturbance. CONCLUSIONS SRS may be an alternative primary treatment option for CS-invading NFPA if there is no urgent and absolute indication for surgery such as optic apparatus compression.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,
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Breshears JD, Morshed RA, Molinaro AM, McDermott MW, Cheung SW, Theodosopoulos PV. Residual Tumor Volume and Location Predict Progression After Primary Subtotal Resection of Sporadic Vestibular Schwannomas: A Retrospective Volumetric Study. Neurosurgery 2020; 86:410-416. [PMID: 31232426 DOI: 10.1093/neuros/nyz200] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/24/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Preservation of functional integrity during vestibular schwannoma surgery has become critical in the era of patient-centric medical decision-making. Subtotal tumor removal is often necessary when dense adhesions between the tumor and critical structures are present. However, it is unclear what the rate of tumor control is after subtotal resection (STR) and what factors are associated with recurrence. OBJECTIVE To determine the rate of residual tumor growth after STR and identify clinical and radiographic predictors of tumor progression. METHODS A single-institution retrospective study was performed on all sporadic vestibular schwannomas that underwent surgical resection between January 1, 2002 and December 31, 2015. Clinical charts, pathology, radiology, and operative reports were reviewed. Volumetric analysis was performed on all pre- and postoperative MR imaging. Univariate and multivariate logistic regression was performed to identify predictors of the primary endpoint of tumor progression. Kaplan-Meier analysis was performed to compare progression free survival between 2 groups of residual tumor volumes and location. RESULTS In this cohort of 66 patients who underwent primary STR, 30% had documented progression within a median follow up period of 3.1 yr. Greater residual tumor volume (OR 2.0 [1.1-4.0]) and residual disease within the internal auditory canal (OR 3.7 [1.0-13.4]) predicted progression on multivariate analysis. CONCLUSION These longitudinal data provide insight into the behavior of residual tumor, helping clinicians to determine if and when STR is an acceptable surgical strategy and to anchor expectations during shared medical decision-making consultation with patients.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Steven W Cheung
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Kara M, Güdük M, Samanci Y, Yilmaz M, Şengöz M, Peker S. Gamma knife radiosurgery in patients with Cushing's disease: Comparison of aggressive pituitary corticotroph tumor versus corticotroph adenoma. Clin Neurol Neurosurg 2020; 197:106151. [PMID: 32882541 DOI: 10.1016/j.clineuro.2020.106151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/06/2020] [Accepted: 08/09/2020] [Indexed: 10/23/2022]
Abstract
Aggressive pituitary corticotroph tumors causing Cushing's disease are rare, and there is limited data about their clinical management. Here, we aimed to report our long-term experience with gamma knife radiosurgery (GKRS) as adjuvant treatment in patients with residual or recurrent pituitary corticotroph tumors. This retrospective study included 45 adult patients (M/F, 7/38; mean age, 40.2 ± 13.1 years) with residual tumor or recurrence after initially successful surgical resection. Single-session GKRS was performed in all patients. Tumors with a Ki-67 value higher than 3 % and radiologic invasion to surrounding tissues were classified as aggressive tumor group. Clinical, hormonal and radiological findings were compared between the aggressive (n = 10) and non-aggressive adenoma (n = 35) groups. Following GKRS, tumor volumes were significantly reduced in both groups. The mean time to hormonal remission in the non-aggressive group was significantly shorter than in the aggressive group (23.5 ± 6.3 vs 33.0 ± 5.0 month, respectively, p < 0.05). New-onset hypopituitarism was identified in only seven patients (15 %) after GKRS in the whole cohort. The present study introduces several essential findings about aggressive corticotroph tumors. First, aggressive behavior tends to occur more frequently in male subjects. Second, time to GKRS was significantly shorter in the aggressive group. Moreover, a tumor volume ≥2 cm3 may be associated with clinical aggressiveness in corticotroph tumors. In conclusion, we suggest that early adjuvant GKRS is an effective treatment option in aggressive pituitary corticotroph tumors.
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Affiliation(s)
- Müjdat Kara
- Acıbadem University School of Medicine, Department of Endocrinology, İstanbul, Turkey.
| | - Mustafa Güdük
- Acıbadem University School of Medicine, Department of Neurosurgery, İstanbul, Turkey
| | - Yavuz Samanci
- Koç University School of Medicine, Department of Neurosurgery, İstanbul, Turkey
| | - Meltem Yilmaz
- Acıbadem University School of Medicine, Medical Biotechnology Program, İstanbul, Turkey
| | - Meriç Şengöz
- Acıbadem University School of Medicine, Department of Radiation Oncology, İstanbul, Turkey
| | - Selçuk Peker
- Koç University School of Medicine, Department of Neurosurgery, İstanbul, Turkey
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Cordeiro D, Xu Z, Li CE, Iorio-Morin C, Mathieu D, Sisterson ND, Kano H, Attuati L, Picozzi P, Sheehan KA, Lee CC, Liscak R, Jezkova J, Lunsford LD, Sheehan J. Gamma Knife radiosurgery for the treatment of Nelson's syndrome: a multicenter, international study. J Neurosurg 2020; 133:336-341. [PMID: 31299652 DOI: 10.3171/2019.4.jns19273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nelson's syndrome is a rare and challenging neuroendocrine disorder, and it is associated with elevated adrenocorticotrophic hormone (ACTH) level, skin hyperpigmentation, and pituitary adenoma growth. Management options including resection and medical therapy are traditional approaches. Ionizing radiation in the form of Gamma Knife radiosurgery (GKRS) is also being utilized to treat Nelson's syndrome. In the current study the authors sought to better define the therapeutic role of stereotactic radiosurgery (SRS) in Nelson's syndrome. METHODS Study patients with Nelson's syndrome were treated with single-fraction GKRS (median margin dose of 25 Gy) at 6 different centers as part of an International Radiosurgery Research Foundation (IRRF) investigation. Data including neurological function, endocrine response, and radiological tumor response were collected and sent to the study-coordinating center for review. Fifty-one patients with median endocrine and radiological follow-ups of 91 and 80.5 months from GKRS, respectively, were analyzed for endocrine remission, tumor control, and neurological outcome. Statistical methods were used to identify prognostic factors for these endpoints. RESULTS At last follow-up, radiological tumor control was achieved in 92.15% of patients. Endocrine remission off medical management and reduction in pre-SRS ACTH level were achieved in 29.4% and 62.7% of patients, respectively. Improved remission rates were associated with a shorter time interval between resection and GKRS (p = 0.039). Hypopituitarism was seen in 21.6% and new visual deficits were demonstrated in 15.7% of patients. CONCLUSIONS GKRS affords a high rate of pituitary adenoma control and improvement in ACTH level for the majority of Nelson's syndrome patients. Hypopituitarism is the most common adverse effect from GKRS in Nelson's syndrome patients and warrants longitudinal follow-up for detection and endocrine replacement.
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Affiliation(s)
- Diogo Cordeiro
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chelsea E Li
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christian Iorio-Morin
- 2Department of Surgery, Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - David Mathieu
- 2Department of Surgery, Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | | | - Hideyuki Kano
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Luca Attuati
- 4Neurosurgery and Gamma Knife Radiosurgery, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Piero Picozzi
- 4Neurosurgery and Gamma Knife Radiosurgery, Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Kimball A Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 5Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, People's Republic of China; and
| | - Roman Liscak
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jana Jezkova
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - L Dade Lunsford
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jason Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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43
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Akyoldaş G, Şirin A, Yılmaz M, Şengöz M, Peker S. Long-term results of Gamma Knife radiosurgery for facial nerve schwannomas. Neurol Res 2020; 42:1055-1060. [PMID: 32705956 DOI: 10.1080/01616412.2020.1796379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Long-term outcomes of eleven cases of facial nerve schwannoma were evaluated and the related literature was reviewed to determine the efficacy of Gamma Knife radiosurgery for treating patients with facial nerve schwannoma. METHODS Eleven patients with facial nerve schwannoma (7 women and 4 men; mean age, 44.2 years; range, 19-73 years) underwent Gamma Knife radiosurgery. The most common symptoms were facial palsy (n = 10) and hearing loss (n = 7). Five patients presented with headache. Two patients had undergone prior resection. The patients' clinical and radiographic data were evaluated retrospectively. RESULTS For the 11 cases of facial nerve schwannoma, mean tumor volume was 3.1 cm3 (range, 0.4-7.4 cm3) and the mean marginal dose applied was 11.9 Gy (range, 11-13 Gy). The mean follow-up period was 84.3 months (range, 66-117 months). Tumor control was achieved in all patients. At the time of writing, four patients experienced tumor volume regression and the other seven were in stable condition. During follow-up, nine patients experienced no change in their facial function, two experienced deteriorated facial function, and none developed new facial palsy. Ten patients who had serviceable hearing prior to Gamma Knife radiosurgery retained their hearing. CONCLUSIONS Gamma Knife radiosurgery achieves excellent results with respect to tumor control for 7 years on average. In addition, Gamma Knife radiosurgery provides good results in facial nerve and hearing function at long term. Our series demonstrates that Gamma Knife radiosurgery is an effective and safe treatment for patients with either primary or residual facial nerve schwannoma.
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Affiliation(s)
- Göktuğ Akyoldaş
- Department of Neurosurgery, Koç University School of Medicine , Istanbul, Turkey
| | - Alperen Şirin
- Acıbadem Mehmet Ali Aydınlar University School of Medicine , Istanbul, Turkey
| | - Meltem Yılmaz
- Medical Biotechnology, Acıbadem Mehmet Ali Aydınlar University , Istanbul, Turkey
| | - Meriç Şengöz
- Department of Radiation Oncology, Acıbadem Mehmet Ali Aydınlar University School of Medicine , Istanbul, Turkey
| | - Selçuk Peker
- Department of Neurosurgery, Koç University School of Medicine , Istanbul, Turkey
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Park HH, Kim WH, Jung HH, Chang JH, Lee KS, Chang WS, Hong CK. Radiosurgery vs. microsurgery for newly diagnosed, small petroclival meningiomas with trigeminal neuralgia. Neurosurg Rev 2020; 43:1631-1640. [PMID: 32642933 DOI: 10.1007/s10143-020-01346-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 11/26/2022]
Abstract
Trigeminal neuralgia (TN) is an excruciating pain that can occur with petroclival meningiomas (PCMs). Gamma knife radiosurgery (GKRS) is an appealing option for small PCMs, but the role of microsurgery (MS) compared to GKRS is not well defined for small PCMs with regard to TN relief. From January 2009 to September 2019, 70 consecutive patients were treated by GKRS or MS for newly diagnosed, small (< 3.5 cm) PCMs with TN. GKRS or MS were performed for 35 patients each. The surgical outcome and TN control according to Barrow Neurological Institute (BNI) score were retrospectively analyzed and compared between GKRS and MS. The predominant origin of PCMs was upper clival (49%) with trigeminal nerve compression at the medial dorsal root entry zone. Tumor control rates were equally 94% with GKRS or MS for a mean tumor size and volume of 2.3 cm and 5.3 cm3, respectively. The preoperative BNI scores were mostly II (40%) and IV (37%) with GKRS and MS, respectively. TN relief without medications (BNI scores I and II) was achieved in 13 of 35 patients (37%) with GKRS and 32 of 35 patients (91%) with MS during a mean follow-up of 50.5 months. The most common complications after GKRS and MS were dysesthesia (23%) and diplopia (9%), respectively. MS could be more effective than GKRS in providing prompt, medication-free pain relief from TN for small PCMs. The risks of MS have to be considered carefully in experienced hands, especially for small PCMs.
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Affiliation(s)
- Hun Ho Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Woo Hyun Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Hyun-Ho Jung
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Gamma Knife Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
- Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
- Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Gamma Knife Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
- Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
- Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Kyu-Sung Lee
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Gamma Knife Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
- Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
- Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea.
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45
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Lin YY, Wu HM, Yang HC, Chen CJ, Lin CJ, Chen YW, Chen HH, Wong TT, Hu YS, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Repeated gamma knife radiosurgery enables longer tumor control in cases of highly-recurrent intracranial ependymoma. J Neurooncol 2020; 148:363-372. [PMID: 32405998 DOI: 10.1007/s11060-020-03531-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/05/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is a potential re-irradiation treatment for recurrent intracranial ependymoma after prior radiation therapy. The purpose of this study was to examine the efficacy and safety of repeated SRS in the treatment of recurrent intracranial ependymomas. METHODS This is a retrospective study of consecutive patients with residual or recurrent intracranial ependymomas who were treated with SRS between 1993 and 2018. Tumor progression was defined as a ≥ 10% increase in tumor volume. Tumor regression was defined as a ≥ 10% reduction in tumor volume. A tumor that remained within 10% of its original volume was defined as stable. Tumor control comprised tumor regression and stability. Time-dependent analyses were performed using two treatment failure endpoint definitions: (1) evidence of local tumor progression or distant metastasis (single SRS analysis), and (2) lack of tumor response to SRS (repeated SRS analysis). These analyses were adjusted for the competing risk of death. RESULTS The study comprised 37 patients (65 intracranial ependymomas) who underwent multiple SRS sessions (range: 1-7). Median age was 10.2 years (range: 0.8-53.8 years), and median tumor volume was 1.5 mL (range: 0.01-22.5 mL). The median radiation dose was 13.3 Gy (range: 7.9-22.0 Gy) at a median isodose line of 57% (range: 50-90%). Overall tumor control rates in the single SRS analysis adjusting for the competing risk of death were 53.6%, 30.5%, and 23.6% at 1, 3, and 5 years, respectively. Overall tumor control rates in the repeated SRS analysis adjusting for the competing risk of death were 70.6%, 50.4%, and 43.1% at 1, 3, and 5 years, respectively. Prior gross total resection was the only independent predictor of overall tumor control after SRS (aHR = 25.62 (1.55-422.1), p = 0.02). CONCLUSIONS Repeated GKRS appeared to be an effective treatment strategy for recurrent or residual intracranial ependymomas, with acceptable complication rates.
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Affiliation(s)
- Yen-Yu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Hung Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tai-Tong Wong
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
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46
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Pomeraniec IJ, Taylor DG, Cohen-Inbar O, Xu Z, Lee Vance M, Sheehan JP. Radiation dose to neuroanatomical structures of pituitary adenomas and the effect of Gamma Knife radiosurgery on pituitary function. J Neurosurg 2020; 132:1499-1506. [PMID: 30978685 DOI: 10.3171/2019.1.jns182296] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) provides a safe and effective management option for patients with all types of pituitary adenomas. The long-term adverse effects of targeted radiation to the hypothalamic-pituitary axis in relationship to radiation dose remain unclear. In this retrospective review, the authors investigated the role of differential radiation doses in predicting long-term clinical outcomes and pituitary function after GKRS for pituitary adenomas. METHODS A cohort of 236 patients with pituitary tumors (41.5% nonfunctioning, 58.5% functioning adenomas) was treated with GKRS between 1998 and 2015. Point dosimetric measurements, with no minimum volume, to 14 consistent points along the hypothalamus bilaterally, pituitary stalk, and normal pituitary were made. Statistical analyses were performed to determine the impact of doses to critical structures on clinical, radiological, and endocrine outcomes. RESULTS With a median follow-up duration of 42.9 months, 18.6% of patients developed new loss of pituitary function. The median time to endocrinopathy was 21 months (range 2-157 months). The median dose was 2.1 Gy to the hypothalamus, 9.1 Gy to the pituitary stalk, and 15.3 Gy to the normal pituitary. Increasing age (p = 0.015, HR 0.98) and ratio of maximum dose to the pituitary stalk over the normal pituitary gland (p = 0.013, HR 0.22) were independent predictors of new or worsening hypopituitarism in the multivariate analysis. Sex, margin dose, treatment volume, nonfunctioning adenoma status, or ratio between doses to the pituitary stalk and hypothalamus were not significant predictors. CONCLUSIONS GKRS offers a low rate of delayed pituitary insufficiency for pituitary adenomas. Doses to the hypothalamus are low and generally do not portend endocrine deficits. Patients who are treated with a high dose to the pituitary stalk relative to the normal gland are at higher risk of post-GKRS endocrinopathy. Point dosimetry to specific neuroanatomical structures revealed that a ratio of stalk-to-gland radiation dose of 0.8 or more significantly increased the risk of endocrinopathy following GKRS. Improvement in the gradient index toward the stalk and normal gland may help preserve endocrine function.
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Affiliation(s)
| | | | - Or Cohen-Inbar
- Departments of1Neurosurgery
- 4Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Mary Lee Vance
- Departments of1Neurosurgery
- 3Medicine and Endocrinology, University of Virginia Health Science Center, Charlottesville, Virginia; and
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47
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Mohammed N, Ding D, Hung YC, Xu Z, Lee CC, Kano H, Martínez-Álvarez R, Martínez-Moreno N, Mathieu D, Kosak M, Cifarelli CP, Katsevman GA, Lunsford LD, Vance ML, Sheehan JP. Primary versus postoperative stereotactic radiosurgery for acromegaly: a multicenter matched cohort study. J Neurosurg 2020; 132:1507-1516. [PMID: 31026829 PMCID: PMC7418066 DOI: 10.3171/2019.1.jns183398] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/24/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The role of primary stereotactic radiosurgery (SRS) in patients with medically refractory acromegaly who are not operative candidates or who refuse resection is poorly understood. The aim of this multicenter, matched cohort study was to compare the outcomes of primary versus postoperative SRS for acromegaly. METHODS The authors reviewed an International Radiosurgery Research Foundation database of 398 patients with acromegaly who underwent SRS and categorized them into primary or postoperative cohorts. Patients in the primary SRS cohort were matched, in a 1:2 ratio, to those in the postoperative SRS cohort, and the outcomes of the 2 matched cohorts were compared. RESULTS The study cohort comprised 78 patients (median follow-up 66.4 months), including 26 and 52 in the matched primary and postoperative SRS cohorts, respectively. In the primary SRS cohort, the actuarial endocrine remission rates at 2 and 5 years were 20% and 42%, respectively. The Cox proportional hazards model showed that a lower pre-SRS insulin-like growth factor-1 level was predictive of initial endocrine remission (p = 0.03), whereas a lower SRS margin dose was predictive of biochemical recurrence after initial remission (p = 0.01). There were no differences in the rates of radiological tumor control (p = 0.34), initial endocrine remission (p = 0.23), biochemical recurrence after initial remission (p = 0.33), recurrence-free survival (p = 0.32), or hypopituitarism (p = 0.67) between the 2 matched cohorts. CONCLUSIONS Primary SRS has a reasonable benefit-to-risk profile for patients with acromegaly in whom resection is not possible, and it has similar outcomes to endocrinologically comparable patients who undergo postoperative SRS. SRS with medical therapy in the latent period can be used as an alternative to surgery in selected patients who cannot or do not wish to undergo resection.
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Affiliation(s)
- Nasser Mohammed
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | | | | | - David Mathieu
- Department of Neurological Surgery, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Mikulas Kosak
- 3rd Department of Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Gennadiy A. Katsevman
- Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Mary Lee Vance
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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48
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Moraes FY, Winter J, Atenafu EG, Dasgupta A, Raziee H, Coolens C, Millar BA, Laperriere N, Patel M, Bernstein M, Kongkham P, Zadeh G, Conrad T, Chung C, Berlin A, Shultz DB. Outcomes following stereotactic radiosurgery for small to medium-sized brain metastases are exceptionally dependent upon tumor size and prescribed dose. Neuro Oncol 2020; 21:242-251. [PMID: 30265328 DOI: 10.1093/neuonc/noy159] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND At our institution, we have historically treated brain metastasis (BM) ≤2 cm in eloquent brain with a radiosurgery (SRS) lower prescription dose (PD) to reduce the risk of radionecrosis (RN). We sought to evaluate the impact of this practice on outcomes. METHODS We analyzed a prospective registry of BM patients treated with SRS between 2008 and 2017. Incidences of local failure (LF) and RN were determined and Cox regression was performed for univariate and multivariate analyses (MVAs). RESULTS We evaluated 1533 BM ≤2 cm. Median radiographic follow-up post SRS was 12.7 months (1.4-100). Overall, the 2-year incidence of LF was lower for BM treated with PD ≥21 Gy (9.3%) compared with PD ≤15 Gy (19.5%) (sub-hazard ratio, 2.3; 95% CI: 1.4-3.7; P = 0.0006). The 2-year incidence of RN was not significantly higher for the group treated with PD ≥21 Gy (9.5%) compared with the PD ≤15 Gy group (7.5%) (P = 0.16). MVA demonstrated that PD (≤15 Gy) and tumor size (>1 cm) were significantly correlated (P < 0.05) with higher rates of LF and RN, respectively. For tumors ≤1 cm, when comparing PD ≤15 Gy with ≥21 Gy, the risks of LF and RN are equivalent. However, for lesions >1 cm, PD ≥21 Gy is associated with a lower incidence of LF without significantly increasing the risk of RN. CONCLUSION Our results indicate that rates of LF or RN following SRS for BM are strongly correlated with size and PD. Based on our results, we now, depending upon the clinical context, consider increasing PD to 21 Gy for BM in eloquent brain, excluding the brainstem.
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Affiliation(s)
- Fabio Y Moraes
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff Winter
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Hamid Raziee
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Coolens
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Maitry Patel
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kongkham
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Mastorakos P, Xu Z, Yu J, Hess J, Qian J, Chatrath A, Taylor DG, Kondziolka D, Warnick R, Chiang V, Sheehan J. BRAF V600 Mutation and BRAF Kinase Inhibitors in Conjunction With Stereotactic Radiosurgery for Intracranial Melanoma Metastases: A Multicenter Retrospective Study. Neurosurgery 2020; 84:868-880. [PMID: 29846702 DOI: 10.1093/neuros/nyy203] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/17/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The BRAF mutation has been identified as a potent target for the treatment of metastatic melanoma and BRAF inhibitors (BRAFi) have demonstrated promising results against melanoma brain metastases (BM). OBJECTIVE To further investigate the effectiveness of this combined treatment regimen. METHODS In this multicenter retrospective cohort study, 198 patients with known BRAF mutation status and treated with stereotactic radiosurgery (SRS) between 2011 and 2015 were identified. Kaplan-Meier methodology and multivariate regression analysis was then used to compare survival based on each parameter. RESULTS The median survival after the diagnosis of BM in patients with BRAF mutation who received BRAFi was increased compared to survival in patients with wild-type BRAF (BRAF wt). In multivariate analysis, the BRAF mutation was an independent, positive prognostic factor with a hazard ratio of 0.59. BRAF mutated Patients who received BRAFi following SRS had improved survival compared to patients who received it before (P < .001) or concurrently (P = .007). PD-1 inhibitors improved survival, with more pronounced effect in patients not carrying the BRAF mutation. Among the patients who were treated with BRAFi, 10.4% developed intracerebral hematoma (ICH), in comparison to 3% of patients who were not treated with BRAFi (P = .03). CONCLUSION In the setting of widespread use of BRAFi, the presence of a BRAF mutation is an independent predictor of better prognosis in patients with melanoma BM that underwent SRS. The effect of BRAFi is optimal when treatment is initiated at least 1 wk following SRS. BRAFi may increase the frequency of asymptomatic ICH.
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Affiliation(s)
- Panagiotis Mastorakos
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.,Department of Neurological Surgery, National Institutes of Health, Bethesda, Maryland
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - James Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Judith Hess
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Jack Qian
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Ajay Chatrath
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Ronald Warnick
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Veronica Chiang
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.,Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
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50
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Magnetic resonance imaging for brain stereotactic radiotherapy : A review of requirements and pitfalls. Strahlenther Onkol 2020; 196:444-456. [PMID: 32206842 PMCID: PMC7182639 DOI: 10.1007/s00066-020-01604-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022]
Abstract
Due to its superior soft tissue contrast, magnetic resonance imaging (MRI) is essential for many radiotherapy treatment indications. This is especially true for treatment planning in intracranial tumors, where MRI has a long-standing history for target delineation in clinical practice. Despite its routine use, care has to be taken when selecting and acquiring MRI studies for the purpose of radiotherapy treatment planning. Requirements on MRI are particularly demanding for intracranial stereotactic radiotherapy, where accurate imaging has a critical role in treatment success. However, MR images acquired for routine radiological assessment are frequently unsuitable for high-precision stereotactic radiotherapy as the requirements for imaging are significantly different for radiotherapy planning and diagnostic radiology. To assure that optimal imaging is used for treatment planning, the radiation oncologist needs proper knowledge of the most important requirements concerning the use of MRI in brain stereotactic radiotherapy. In the present review, we summarize and discuss the most relevant issues when using MR images for target volume delineation in intracranial stereotactic radiotherapy.
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