Stereotactic radiosurgery versus stereotactic radiotherapy in the management of intracranial meningiomas: a systematic review and meta-analysis

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) have been used as a primary treatment or adjuvant to resection in the management of intracranial meningiomas (ICMs). The aim of this analysis is to compare the safety and long-term efficacy of SRS and SRT in patients with primary or recurrent ICMs.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A systematic review of the literature comparing SRT and SRS in the same study was conducted using PubMed, the Cochrane Library, Google Scholar, and EMBASE from January 1980 to December 2018. Randomized controlled trials, case-control studies, and cohort studies (prospective and retrospective) analyzing SRS versus SRT for the treatment of ICMs in adult patients (age &gt; 16 years) were included. Pooled and subgroup analyses were based on the fixed-effect model.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 1736 patients from 12 retrospective studies were included. The treatment modality used was: 1) SRS (n = 306), including Gamma Knife surgery (n = 36), linear accelerator (n = 261), and CyberKnife (n = 9); or 2) SRT (n = 1430), including hypofractionated SRT (hFSRT, n = 268) and full-fractionated SRT (FSRT, n = 1162). The median age of patients at the time of treatment was 59 years. The median follow-up duration after treatment was 35.5 months. The median tumor volumes at the time of treatment with SRS, hFSRT, and FSRT were 2.84 cm<jats:sup>3</jats:sup>, 5.45 cm<jats:sup>3</jats:sup>, and 12.75 cm<jats:sup>3</jats:sup>, respectively. The radiographic tumor control at last follow-up was significantly worse in patients who underwent SRS than SRT (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.27–0.82, p = 0.007) with 7% less volume of tumor shrinkage (OR 0.93, 95% CI 0.61–1.40, p = 0.72). Compared to SRS, the radiographic tumor control was better achieved by FSRT (OR 0.46, 95% CI 0.26–0.80, p = 0.006) than by hFSRT (OR 0.81, 95% CI 0.21–3.17, p = 0.76). Moreover, SRS leads to a significantly higher risk of clinical neurological worsening during follow-up (OR 2.07, 95% CI 1.06–4.06, p = 0.03) and of immediate symptomatic edema (OR 4.58, 95% CI 1.67–12.56, p = 0.003) with respect to SRT. SRT could produce a better progression-free survival at 4–10 years compared to SRS, but this was not statistically significant (p = 0.29).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>SRS and SRT are both safe options in the management of ICMs. However, SRT carries a better radiographic tumor control rate and a lower incidence of posttreatment symptomatic worsening and symptomatic edema, with respect to SRS. However, further prospective studies are still needed to validate these results.</jats:p></jats:sec>

Association between tumor size and peritumoral brain edema in patients with convexity and parasagittal meningiomas

“…To the best of our knowledge, this is the first study to suggest an optimal cut-off value for meningioma volume that predicts PTBE in patients with convexity and parasagittal meningiomas. Determining whether to treat small or large meningiomas with stereotactic radiosurgery or fractionated stereotactic radiotherapy or surgery based on a meningioma diameter of 3 cm without any specific reference studies or data has been accomplished by implicit consent among clinicians [ 9 – 13 ]. Therefore, we believe that our findings may be valuable because we have shown why a meningioma 3 cm diameter can be established as a clinically meaningful standard for the treatment of convexity and parasagittal meningiomas.…”

“…Therefore, we wanted to evaluate the pure association between meningioma size and PTBE occurrence without surgery or radiation therapy in patients with meningiomas at similar locations. In addition, based on clinical experience or implicit consent, most physicians decided on whether to perform surgery or initiate radiation treatment based on a meningioma diameter of 3 cm, without any scientific reference [ 9 – 13 ]. Therefore, to verify the validity of this size as a clinically meaningful standard for treatment, we needed to evaluate the cut-off value for meningioma size that predicts PTBE development in patients with meningiomas.…”

Treatment of intracranial meningioma with single-session and fractionated radiosurgery: a propensity score matching study

“…Manabe et al using LINAC-based FSRT (25 Gy in 2–10 fractions) in 14 patients with tumor volume > 13.5 cm 3 reported that the 3-year progression-free survival rate was 69% 21 . In a systemic review, despite the potential systemic error in the measurement, Fatima et al proposed that the larger tumors treated with FSRT (5–10 fractions) are significantly associated with better LCR and with higher extent of tumor shrinkage compared with the smaller tumors treated with SRS (< 5 fractions; p = 0.007 and p = 0.72, respectively) 22 . Han et al compared the effectiveness of SSRS (n = 42) and FSRT (n = 28) in the treatment of large meningiomas (> 10 cm 3 ); there were 16 skull base meningioma in FSRT group.…”

Machine Learning Algorithms Using Logistic Regression for Predicting Neurosurgical Outcomes

“…The treatment of neurosurgical diseases have been revolutionized due to greater stride observed in terms of systematic therapy, radiotherapy, and surgical techniques 1-3 , 4,5,6,78,9 . The multimodal management has resulted in achieving better clinical and functional outcomes 13,14 .…”