International Journal of Radiation Oncology*Biology*Physics
Clinical investigationEfficacy and morbidity of arc-therapy radiosurgery for cerebral arteriovenous malformations: a comparison with the natural history
Introduction
The choice of therapeutic modality to treat cerebral arteriovenous malformations (AVMs) is highly controversial. These lesions, when untreated, represent a consequential threat to patients, with an annual rate of major hemorrhage of 2–17% 1, 2, 3, 4. Intracerebral hemorrhages have been reported as lethal in up to 29% of cases (2). During the past decades, surgery has been considered the standard treatment by many authors (5). The treatment of AVM by radiosurgery still raises controversy. Some have supported the option of observation for inoperable AVMs rather than nonsurgical treatment, because only scant evidence is available regarding the value of nonsurgical treatment in terms of survival, quality of life, and neurologic progression-free survival (6). We therefore compared the actuarial rates of hemorrhage and severe complication-free survival of our series of patients with that observed in the natural history of untreated AVMs.
Section snippets
Patients
At the University Hospital of Nancy, 217 patients have been treated by linear accelerator radiosurgery since 1992. We report the results of a retrospective study of the 118 first patients (55 men and 63 women) treated between July 1, 1992 and June 30, 1998 (Table 1, Table 2). The closing date of the study was December 31, 2001. The mean follow-up was 46 months (range, 5–105 months; median, 44 months). Of the 118 patients, 2 (2%) were lost to follow-up. The mean age was 35 years (range, 13–65
Efficacy
The cure rate was 54% (60 of 112) among patients evaluated by either angiography or MRI. All cures were confirmed by angiography. When only considering evaluations performed at least 18 months after radiosurgery, the cure rate was 57% (60 of 106). The actuarial cure rate was 77% (range, 76.9–77.1%) at 5 years (Fig. 1). One patient developed a new contralateral AVM. Of 112 patients, 83 (74%) reached cure or a reduction of >95% of their initial volume.
Prognostic factors of cure
No statistically significant differences
Discussion
Therapeutic decision-making for cerebral AVMs is particularly difficult. AVMs present a statistical risk of intracerebral hemorrhage with resulting functional and even vital complications at stake. Physicians who are confronted with this issue are either determined to treat or extremely reluctant. For this reason, randomized studies have proved very difficult. All effort must therefore be made to appreciate, with the highest precision, the statistical gain achieved by treatment as opposed to no
Conclusion
The results of our series show that our treatment strategy, with radiosurgery performed alone or after prior shrinkage of the AVM volume by embolization, is both effective (5-year actuarial cure rate 77%) and well tolerated, with a rate of adverse effects (complications and/or hemorrhage) comparable to that of untreated patients and with no mortality. Our results also confirmed the importance of size (±7 cm3) as a curative prognostic factor. No hemorrhage occurred in patients after either total
Acknowledgements
The authors thank M. Maire for her helpful collaboration in the preparation of this manuscript.
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