The principles of skull base radiosurgery

Kondziolka, Douglas; Flickinger, John C.; Lunsford, L. Dade

doi:10.3171/foc/2008/24/5/e11

Cited by 33 publications

(31 citation statements)

References 19 publications

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“…13 Furthermore, the trend of reduced marginal doses to around 12 Gy has proven just as efficacious for tumor control as higher doses, while limiting radiation dosage to nearby neurovascular structures. 22,28,46 Ganz et al recommended that the marginal dose be kept at 12 Gy and only reduced if it was necessary to protect normal tissue. 16 Hypofractionated or multisession radiosurgical procedures also offers steep radiation falloff to protect adjacent tissue from radiation-induced injury.…”

Section: Discussionmentioning

confidence: 99%

“…Traditionally, a tumor diameter of 30-35 mm was the recommended cutoff for radiosurgery. [30][31][32] In prior studies, large meningiomas have been treated with varying degrees of success, but radiosurgery outcomes appear to worsen for patients harboring meningiomas greater than 8 cm 3 in volume. 8,15,16,20,42 An 8-cm 3 volume corresponds to a lesion with an approximate diameter of 2.5 cm.…”

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Gamma Knife radiosurgery of large skull base meningiomas

Starke¹,

Przybylowski²,

Mukherjee

et al. 2015

JNS

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M eningioMas are the most frequently reported primary intracranial neoplasms in the US. Most of these lesions are benign (i.e., WHO Grade I) with a low tendency for invasion and recurrence and a natural history of slow growth. Within the intracranial space, there is a narrow capacity for mass expansion. The primary approach for large meningiomas has been resection. Despite a dramatic decline in surgical morbidity for abbreviatioNs CN = cranial nerve; CPA = cerebellopontine angle; GKRS = Gamma Knife radiosurgery; HR = hazard ratio; SRS = stereotactic radiosurgery. submitted January 26, 2014. accepted October 14, 2014. iNclude wheN citiNg Published online December 5, 2014; DOI: 10.3171/2014.10.JNS14198. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. obJect Stereotactic radiosurgery (SRS) has become a common treatment modality for intracranial meningiomas. Skull base meningiomas greater than 8 cm 3 in volume have been found to have worse outcomes following SRS. When symptomatic, patients with these tumors are often initially treated with resection. For tumors located in close proximity to eloquent structures or in patients unwilling or unable to undergo a resection, SRS may be an acceptable therapeutic approach. In this study, the authors review the SRS outcomes of skull base meningiomas greater than 8 cm 3 in volume, which corresponds to a lesion with an approximate diameter of 2.5 cm. methods The authors reviewed the data in a prospectively compiled database documenting the outcomes of 469 patients with skull base meningiomas treated with single-session Gamma Knife radiosurgery (GKRS). Seventy-five patients had tumors greater than 8 cm 3 in volume, which was defined as a large tumor. All patients had a minimum follow-up of 6 months, but patients were included if they had a complication at any time point. Thirty patients were treated with upfront GKRS, and 45 were treated following microsurgery. Patient and tumor characteristics were assessed to determine predictors of new or worsening neurological function and tumor progression following GKRS. results After a mean follow-up of 6.5 years (range 0.5-21 years), the tumor volume was unchanged in 37 patients (49%), decreased in 26 patients (35%), and increased in 12 patients (16%). Actuarial rates of progression-free survival at 3, 5, and 10 years were 90.3%, 88.6%, and 77.2%, respectively. Four patients had new or worsened edema following GKRS, but preexisting edema decreased in 3 patients. In Cox multivariable analysis, covariates associated with tumor progression were 1) presentation with any cranial nerve (CN) deficit from III to VI (hazard ratio [HR] 3.78, 95% CI 1.91-7.45; p < 0.001), history of radiotherapy (HR 12.06, 95% CI 2.04-71.27; p = 0.006), and tumor volume greater than 14 cm 3 (HR 6.86, p = 0.066). In those patients with detailed clinical follow-up (n = 64), neurological function was unchanged in 37 patients (58%), improved in 16 patients (25%), and d...

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Gamma Knife radiosurgery of large skull base meningiomas

Starke¹,

Przybylowski²,

Mukherjee

et al. 2015

JNS

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“…Initially, 4-mm isocenters were used on the part of the lesion adjacent to the critical structures, such as visual pathways and cranial nerves within the lateral wall of the cavernous sinus. 28) If possible the latter was not covered with the prescription isodose. Thereafter, 4-mm and 8-mm isocenters with various weights were placed on the bulk of the tumor, compactly located within its border.…”

Section: Methodsmentioning

confidence: 99%

Gamma Knife Radiosurgery for Benign Cavernous Sinus Tumors: Treatment Concept and Outcomes in 120 Cases

Hayashi

Chernov

Tamura

et al. 2012

Neurol. Med. Chir.(Tokyo)

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Availability of modern computer-aided robotized devices, such as the Automatic Positioning System (APS TM ; Elekta Instruments AB, Stockholm, Sweden) and Perfexion TM (Elekta Instruments AB), allowed us to develop the original concept of robotic gamma knife microradiosurgery, which is based on the very precise irradiation of the lesion with regard to conformity and selectivity; intentional avoidance of the excessive irradiation of functionally-important anatomical structures, particularly cranial nerves, located both within and in the vicinity of the target; and delivery of sufficient irradiation energy to the tumor with the intention to attain lesion shrinkage, while keeping the marginal dose sufficiently low for prevention of possible complications. The results of such treatment strategy were evaluated retrospectively in 120 patients with benign cavernous sinus neoplasms (pituitary adenomas, meningiomas, schwannomas, and hemangiomas), who were followed up from 24 to 78 months (mean 47 months) after radiosurgery. Tumor growth control and shrinkage rates were 98% and 68%, respectively. More than 50% volume reduction was noted in 25% of lesions. The most prominent volumetric tumor response was observed in hemangiomas, followed by schwannomas, pituitary adenomas, and meningiomas. Treatment-related complications were marked in 7% of cases, and were mainly related to transient isolated cranial neuropathy appearing within several months after radiosurgery. Major morbidity was limited to one patient (0.8%). Application of microradiosurgical treatment principles provides effective and safe management of benign cavernous sinus tumors and is associated with high probability of lesion shrinkage and minimal risk of complications.

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“…During these same 30 years, SRS has found an increasing role as a primary treatment for brain tumors that have definable tumor borders or as adjuvant therapy within a paradigm of multimodality management in patients with infiltrative tumor borders [15][16][17] . For patients who have surgically unresectable neoplasms confirmed by stereotactic biopsy, radiosurgery may be an initial treatment option [17][18][19] .…”

Section: The Rationale For Same-day Stereotactic Proceduresmentioning

confidence: 99%

Combining Brain Diagnosis and Therapy in a Single Strategy: The Safety, Reliability, and Cost Implications Using Same-Day versus Separate-Day Stereotactic Procedures

Park

Niranjan

Kondziolka

et al. 2011

Stereotact Funct Neurosurg

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Background: A therapeutic radiosurgery procedure usually follows a separate diagnostic stereotactic procedure after days or weeks. Objectives: To define the clinical reliability, safety, and cost implications of same-day diagnostic stereotactic biopsy and therapeutic radiosurgery. Methods: During an 8-year interval, 26 patients underwent stereotactic brain biopsy followed by immediate therapeutic stereotactic radiosurgery in a single-day combined procedure. The intraoperative diagnosis was determined using standard histopathological techniques. Diagnostic accuracy, hospital costs, and contribution margins associated with this treatment strategy were compared to those of 26 case-matched patients (controls) who underwent a stereotactic diagnostic procedure followed by a separate-day outpatient SRS procedure within 6 weeks during the same time interval. Results: The intraoperative diagnosis correlated with the final histopathological diagnosis in 96% of the patients. Biopsy-related morbidity did not occur in this series. The mean total costs of same-day patients was significantly lower than the costs of patients who had two-stage procedures (USD 9,077 ± 2,366 vs. 11,284 ± 3,025; p = 0.008). The net contribution to the hospital margin of USD 13,736 was not significantly different between the two management strategies. Conclusions: The advantages of the same-day approach included a single stereotactic head frame application, reduced total admission time, consecutive histopathological diagnosis and therapy in a single hospital admission, and reduced total hospital costs. For patients who are highly suspected to have a brain tumor for which SRS is likely to be an effective therapeutic strategy, same-day diagnostic stereotactic biopsy followed by therapeutic SRS proved to be a safe, reliable, and cost-effective management strategy.

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The principles of skull base radiosurgery

Cited by 33 publications

References 19 publications

Gamma Knife radiosurgery of large skull base meningiomas

Gamma Knife radiosurgery of large skull base meningiomas

Gamma Knife Radiosurgery for Benign Cavernous Sinus Tumors: Treatment Concept and Outcomes in 120 Cases

Combining Brain Diagnosis and Therapy in a Single Strategy: The Safety, Reliability, and Cost Implications Using Same-Day versus Separate-Day Stereotactic Procedures

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