Intensity-Modulated Radiotherapy for Complex-Shaped Meningioma of the Skull Base: Long-Term Experience of a Single Institution

doi:10.1016/j.ijrobp.2006.12.073

International Journal of Radiation OncologyBiologyPhysics

Volume 68, Issue 3, 1 July 2007, Pages 858-863

Presented at the 48th Annual Meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO), Philadelphia, PA, November 5–9, 2006.

https://doi.org/10.1016/j.ijrobp.2006.12.073 Get rights and content

Purpose: We analyzed our long-term experience with intensity-modulated radiotherapy (IMRT) in patients with complex-shaped meningioma of the skull base.

Patients and Methods: Between January 1998 and December 2004, 94 patients with complex-shaped meningioma were treated using IMRT at our institution. Tumor distribution was: World Health Organization (WHO) Grade 1 in 54.3%, WHO Grade 2 in 9.6%, and WHO Grade 3 in 4.2%. In 31.9% of patients, the clinical and radiologic characteristics of the tumor were consistent with the diagnosis of meningioma. Twenty-six patients received radiotherapy as primary treatment and 14 patients postoperative for residual disease. Fifty-four patients were treated after local recurrence. Median target volume was 81.4 mL, median total dose was 57.6 Gy given in 32 fractions.

Results: Median follow-up was 4.4 years. Overall local control was 93.6%. Sixty-nine patients had stable disease based on computed tomography/magnetic resonance imaging (MRI), whereas 19 had a tumor volume reduction after IMRT. Six patients showed local tumor progression on MRI 22.3 months’ median after IMRT. Three patients died from non–treatment-related conditions after IMRT. In 39.8% of the patients, preexisting neurologic deficits improved. Worsening of preexisting neurologic symptoms was seen in 4 patients and 2 patients developed new clinical symptoms from local tumor progression. Transient side effects such as headache were seen in 7 patients. Treatment-induced loss of vision was seen in 1 of 53 reirradiated patients with a Grade 3 meningioma 9 months after retreatment with IMRT.

Conclusion: These data demonstrate that IMRT is an effective and safe treatment modality for long-term local control of complex-shaped and otherwise difficult to treat meningioma.

Introduction

Meningiomas are the most common nonglial primary brain tumors, representing approximately 15% of all central nervous system tumors in adults with a predomination in women (1, 2). Using the World Health Organization (WHO) criteria, most meningiomas are histologic benign and slow-growing lesions (3). Treatment of primary choice is complete surgical resection (4, 5). Because of their proximity to critical structures, especially the optical system, cranial nerves and brainstem, and neurovascular system, meningioma may often not be amenable to a safe and complete surgical approach. After subtotal resection, meningioma show a high tendency for local recurrence. Therefore, postoperative radiation therapy is necessary to prevent local tumor recurrence (6, 7). In the literature, 5-year local tumor control rates in patients with benign meningioma reported to range from 89% to 100% after radiosurgery and fractionated stereotactic radiation therapy compared with 85% at 10 years after conventional radiotherapy (8, 9, 10, 11). Intensity-modulated radiation therapy (IMRT) as an advanced form of three-dimensional conformal radiation therapy has been shown to have the ability to conform the dose to concavities and to better avoid organs at risk (12, 13, 14). IMRT allows the modulation of beam intensity to achieve the desired dose distribution for the planning target volume and radiosensitive critical structures by using inverse planning strategies, optimization algorithms, and dose constraints.

The present article is an analysis of our long-term experience with IMRT in the treatment of complex-shaped meningioma, and meningioma that are adherent to, or encompass, critical structures with respect to long-term local tumor control, as well as side effects of irradiation and overall survival of the patients.

Section snippets

Patients and Methods

Between January 1998 and December 2004, 94 patients with a median age of 57.2 years (range, 13.3–79.2 years) were treated with IMRT at the German Cancer Research Center, Heidelberg, Germany. The male/female ratio was 1:3.6 (25:69) patients; median Karnofsky performance score was 90%. Sixty-four patients had a histologic-proven diagnosis of meningioma. In 30 patients, no biopsy was obtained because of the high risk of permanent neurologic deficits, but the clinical and radiologic characteristics

Results

Median follow-up was 4.4 years (range, 1.6–82.7 months). A total of 97% of the patients (91/94 patients) were followed for more than 12 months and 75.5% (71/94 patients) for more than 36 months.

Discussion

As reported in the literature, radiotherapy is capable of improving local tumor control if complete surgical resection of a meningioma is not achievable. Therefore, the indication of radiotherapy treatment is accepted for residual, unresectable meningiomas and in recurrent disease. Especially complex-shaped skull base tumors are a challenge to the radiation oncologist because of their proximity to critical radiosensitive structures. IMRT improves local control in these difficult to treat tumors

Conclusion

These data demonstrate that IMRT is an effective and safe treatment modality for long-term local control of especially complex-shaped and otherwise difficult to treat meningioma of the skull base with lower risk for adverse effects. Furthermore, IMRT offers the possibility of highly conformal irradiation, while sparing adjacent critical radiosensitive structures with the potential of dose escalation for malignant meningiomas.

References (31)

J. Glaholm et al.
The role of radiotherapy in the management of intracranial meningeomasThe Royal Merden Hospital experience with 186 patients
Int J Radiat Oncol Biol Phys
(1990)
A. Pirzkall et al.
Intensity-modulated radiotherapy (IMRT) for recurrent, residual, or untreated skull-base meningiomas: Preliminary clinical experience
Int J Radiat Oncol Biol Phys
(2003)
B.G. Baumert et al.
Intensity-modulated stereotactic radiotherapy vs. stereotactic conformal radiotherapy for the treatment of meningioma located predominantly in the skull base
Int J Radiat Oncol Biol Phys
(2003)
L.J. Verhey
Comparison of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy systems
Semin Radiat Oncol
(1999)
M.A. Keller-Reichenbecher et al.
Intensity modulation with the “step and shoot” technique using a commercial MLC: A planning study
Int J Radiat Oncol Biol Phys
(1999)
D.D. Leavitt et al.
Intensity-modulated radiosurgery/radiotherapy using a micromultileaf collimator
Int J Radiat Oncol Biol Phys
(2001)
S.H. Benedict et al.
Intensity-modulated stereotactic radiosurgery using dynamic micro-multileaf collimation
Int J Radiat Oncol Biol Phys
(2001)
J.T. Parsons et al.
Radiation optic neuropathy after megavoltage external beam irradiation: Analysis of time-dose factors
Int J Radiat Oncol Biol Phys
(1994)
R. Engenhart et al.
Stereotactic single high dose radiation therapy of benign intracranial meningiomas
Int J Radiat Oncol Biol Phys
(1990)
A. Nicolato et al.
The role of Gamma knife radiosurgery in the management of cavernous sinus meningiomas
Int J Radiat Oncol Biol Phys
(2002)

J.R. Rachlin

Etiology and biology of meningeomas

D.S. Russel et al.

R. Mirabell et al.

The role of radiation therapy in the treatment of subtotally resected benign meningiomas

J Neuro-Oncol

(1992)

R.O. Mirimanoff et al.

Meningioma: Analysis of recurrence and progression following neurosurgical resection

J Neurosurg

(1985)

C.B. Wilson

Meningiomas: Genetics, malignancy, and the role of radiation in induction and treatmentThe Richard C. Schneider Lecture

J Neurosurg

(1994)

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Radiation therapy for intracranial lesions is constrained by dose to neurologic organs at risk.
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The incidence of meningiomas is rising and the number of incidental cases is increasing steadily. The efficiency and the safety of each treatment strategy are also improving over time. Therefore the indications to treat meningiomas are constantly changing. The aim of meningioma treatment is keeping the patient fully functional while achieving long-term relief or prevention from problems related to intracranial tumor growth. This chapter reviews the natural history and treatment results and aims to put together the information for the most objective decision-making in treating meningiomas. Factors acting on the treatment decision such as anatomical localization, symptomatology, variations in tumor biology, recurrence status, age and co-morbidities, operative gains, and patient preference are individually discussed.
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Recherche d’une corrélation entre efficacité clinique et radiologique basée sur un suivi volumétrique quantitatif après irradiation de méningiomes de la base du crâne.
Les données de 35 patients pris en charge, soit par tomothérapie hélicoïdale (45,7 %), soit par radiothérapie fractionnée en conditions stéréotaxiques (54,3 %), ont été rétrospectivement analysées. Il s’agissait principalement de femmes (94 %) de 59 ans (43–81) avec des lésions du sinus caverneux (60 %). Il y avait une médiane de 2 (1–4) symptômes par patient, principalement des troubles visuels (39 %), des déficits des nerfs crâniens (23,4 %) et les céphalées (17,2 %).
Le volume tumoral avait significativement diminué (p < 0,05) passant d’une médiane de 9,6 mL (0,3–36,6) à 6,8 mL (0,1–26,5) après un suivi médian de 44 mois (24–77). Une amélioration d’au moins un symptôme a été retrouvée chez 63 % des patients. En analyse unifactorielle, l’efficacité clinique (p < 0,05), la technique de radiothérapie (p < 0,05), la topographie tumorale (p < 0,05) et le volume tumoral initial (p < 0,05) étaient des facteurs prédictifs de la réponse radiologique. En analyse multifactorielle, seule la corrélation inverse entre réponse radiologique et volume tumoral initial demeurait significative (ρ : −0,47 ; intervalle de confiance à 95 % : −3,2–5,7 ; p < 0,05).
Le suivi volumétrique quantitatif permet de mettre en évidence une efficacité radiologique majeure de la radiothérapie. Cependant, aucune corrélation franche entre efficacité clinique et radiologique n’a été retrouvée.
To date, no correlation has been found between clinical and radiological efficacy after irradiation of skull base meningiomas. However, the evaluation of the radiological response was most often made by questionable methods that may have underestimated the radiological effectiveness of radiotherapy. The objective of this work is to verify this hypothesis by quantitative volumetric analysis.
Data from 35 patients treated with either helical tomotherapy (45.7%) or fractionated stereotactic radiotherapy (54.3%) were retrospectively analysed. These were mainly women (94%) aged 59 (43–81) with lesions mainly of the cavernous sinus (60%). There was a median of 2 (1–4) symptoms and the main symptoms were visual impairment (39%), cranial nerve deficits (23.4%) and headaches (17.2%).
Median tumour volume decreased significantly (P < 0.05) from 9.6 mL (0.3–36.6) to 6.8 mL (0.1–26.5) after median follow-up of 44 months (24–77). Sixty-three percent of patients had an improvement of at least one symptom. In univariate analysis, clinical efficacy (P < 0.05), radiotherapy technique (P < 0.05), tumor topography (P < 0.05) and initial tumor volume (P < 0.05) were predictive factors for radiological response. In multivariate analysis, only the inverse correlation between radiological response and initial tumor volume remained significant (ρ: −0.47 95% CI −3.2 to 5.7; P < 0.05).
The quantitative volumetric monitoring demonstrates a major radiological efficiency of radiotherapy. However, no clear correlation between clinical and radiological efficacy was found.
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Advances in neurosurgical techniques and neuroimaging resolution questions the modern-day reliability of the Simpson grade for predicting meningioma recurrence. Therefore, we evaluated the reliability of predictors for recurrence and outcomes in detail in patients with non-skull base meningiomas (NSBMs).
We retrospectively analyzed data from consecutive 175 NSBMs underwent surgical resection. We performed Kaplan–Meier analyses of recurrence-free survival (RFS) according to Simpson and World Health Organization (WHO) grades. Predictors of RFS and clinical deterioration were estimated by univariate and multivariate analyses. Correlation between the Simpson grade and change in Karnofsky Performance Scale scores was assessed by Fisher's exact test.
Log-rank tests revealed significant correlations of both the Simpson and WHO grades with RFS for the overall cohort, convexity, and falx/tentorium meningioma. Unlike patients undergoing Simpson grade I and II resections, RFS in patients with WHO grade I and II/III tumors differed significantly from the early postoperative stage. Multivariate analysis identified tumor size, Simpson grade, and MIB-1 labeling index as significant predictors of RFS. Clinical deterioration was more frequent among patients undergoing less aggressive resection. Tumor location was the only significant predictor of clinical deterioration.
Our findings indicate that tumor size, Simpson and WHO grades, and MIB-1 labeling index are significant predictors of NSBM recurrence. Moreover, the risk of recurrence markedly decreases within the follow-up duration of 80 months. Aggressive resection appears to minimize the risk of recurrence without evidence of clinical deterioration. Follow-up schedules should be based on the WHO grade and extent of resection.
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Clinical investigationBrainIntensity-Modulated Radiotherapy for Complex-Shaped Meningioma of the Skull Base: Long-Term Experience of a Single Institution

Introduction

Section snippets

Patients and Methods

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Semin Radiat Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Etiology and biology of meningeomas

The role of radiation therapy in the treatment of subtotally resected benign meningiomas

J Neuro-Oncol

Meningioma: Analysis of recurrence and progression following neurosurgical resection

J Neurosurg

Meningiomas: Genetics, malignancy, and the role of radiation in induction and treatmentThe Richard C. Schneider Lecture

J Neurosurg

Clinical investigation
Brain
Intensity-Modulated Radiotherapy for Complex-Shaped Meningioma of the Skull Base: Long-Term Experience of a Single Institution