Radiosurgery/Stereotactic Radiotherapy in the Therapeutical Concept for Skull Base Meningiomas

 

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Abstract

Objective: Microsurgical resection is still the treatment of choice for skull base meningiomas. But the risk of postoperative neurological deficits is high, and in many of these cases complete tumor removal cannot be achieved. Therefore recurrences are even more probable. Stereotactically guided radiation therapy - radiosurgery (RS) or stereotactic radiotherapy (SRT) - offers an additional or alternate treatment option for those patients. We evaluated local control rates, symptomatology, and toxicity.

Patients and Methods: 224 patients were treated with stereotactically guided radiation techniques in two departments between 1997 and 2003. 129 of 224 had recurrences after 1 to 3 prior tumor resections and 95 of 224 were treated with SRT/RS alone. 87.9% of cases had benign, 7.8% had atypical and 4.3% had malignant meningiomas. RS was only applied in 11 cases. Tumor volumes ranged from 0.16 ccm to 3.56 ccm. The other 213 patients had larger tumor volumes of up to 135 ccm or a meningioma close to optical structures. Therefore 183 cases were treated with SRT in normal fractions of 1.8-2 Gy in single doses up to 60 Gy. Hypofractionated SRT with single fraction doses of 5 or 4 Gy was applied in 30 cases. Follow-up data were available in 181 skull base meningiomas and the progression-free and overall survival rates, the toxicity and symptomatology were evaluated.

Results: The median follow-up was 36 months. The overall survival and the progression-free survival rates for 5 years were 92.9%, and 96.9%, respectively. Two tumor progressions have occurred to date but further follow up is required. Tumor volumes (TV) had shrunk about by 19.7% at 6 months (p<0.0001) and by 23.2% at 12 months (p<0.01) after SRT/RS. In 95.6% the symptoms had improved or were stable. Clinically significant acute toxicity (grade III) was seen in only 1 case (2.7%). Some patients developed late toxicity: 8.8% had grade I, 4.4% had grade II and 1.1% had grade III. No other neurological deficits occurred during follow-up.

Conclusion: SRT and RS offer an additional or alternative treatment option with a high efficacy and few side effects for the tumor control of skull base meningiomas. An individual and interdisciplinary decision respecting treatment is needed for each patient. In cases of large TV (>4 ccm), tumors adjacent to critical structures (<2 mm) or in high-risk patients the use of SRT offers greater benefits.

Zusammenfassung

Einführung: Die mikrochirurgische Resektion ist immer noch die Therapie der Wahl bei Schädelbasis-Meningeomen. Aber das Risiko postoperativer neurologischer Ausfälle ist hoch. Deshalb kann eine komplette Tumorentfernung oft nicht erreicht werden und Rezidive sind häufiger. Radiochirurgie (RS) oder stereotaktische Radiotherapie (SRT) bieten für diese Patienten eine zusätzliche oder alternative Behandlungsoption. Wir untersuchten die Tumorkontrolle, die Symptomatik und die Komplikationen.

Patienten und Methode: 224 Patienten wurden zwischen 1997 und 2003 in zwei Abteilungen mit SRT oder RS behandelt. 129/224 hatten Rezidive nach 1-3 vorherigen Tumorresektionen und 95/224 keine Vorbehandlung. 87,9% waren benigne, 7,8% atypische und 4,3% maligne Meningeome. Die RS wurde nur bei 11 Fällen mit Tumorvolumina von 0,16-3,56 ccm durchgeführt. Die anderen 213 Patienten hatten ein größeres Tumorvolumen bis zu 135 ccm oder optische Strukturen waren involviert. Deshalb wurden 183 Patienten mit einer SRT in konventioneller Fraktionierung von 1,8-2 Gy Einzeldosen bis zu 60 Gy Gesamtdosis behandelt. Eine hypofraktionierte stereotaktisch geführte Radiatio (SRT) mit Einzeldosen von 5 oder 4 Gy wurde in 30 Fällen appliziert. Die Verlaufsdaten waren von 181 Patienten mit Schädelbasis-Meningeomen verfügbar; deren Tumorkontroll- und Überlebensraten, Toxizität und Symptomatik wurden evaluiert.

Ergebnisse: Die mediane Verlaufsbeobachtung betrug 36 Monate, die 5-Jahres-Überlebens- und Tumorkontrollraten waren 92,9% und 96,9%. Bis jetzt wurden 2 Tumorprogressionen beobachtet - längere Verlaufskontrollen sind natürlich erforderlich. Eine Tumorschrumpfung um 19,7% fand sich 6 Monate nach der SRT/RS (p<0,0001) und um 23,2% nach 12 Monaten (p<0,01). In 95,6% der Fälle verbesserten sich Symptome oder waren unverändert. Es traten klinisch relevante Akuttoxizität in 2,7% und Spätsymptome (Toxizität Grad I: 8,8%, II: 4,4% und III: 1,1%) auf, jedoch keine zusätzlichen neurologischen Ausfälle.

Schlussfolgerung: SRT und RS bieten eine additive oder alternative Behandlungsoption mit hoher Effizienz und wenig Nebenwirkungen für die Tumorkontrolle von Schädelbasis- Meningeomen. Für jeden Patient ist eine individuelle, interdisziplinäre Therapieentscheidung erforderlich. In Fällen mit größerem Tumorvolumen (>4 ccm), bei Beteiligung besonders strahlenempfindlicher Strukturen beziehungsweise bei Hochrisiko-Patienten sollte die SRT bevorzugt werden.

References

• 1 Alheit H, Dornfeld S, Dawel M, Alheit M, Henzel B, Steckler K, Blank H, Geyer P. Patient position reproducibility in fractionated stereotactically guided conformal radiotherapy using the BrainLab mask system.  Strahlenther Onkol. 2001;  177 ((5)) 264-268
  CrossrefPubMedGoogle Scholar
• 2 Al-Mefty O, Kersh JE, Routh A, Smith RR. The long-term side effects of radiation therapy for benign brain tumors in adults.  J Neurosurg. 1990;  73 ((4)) 502-512
  PubMedGoogle Scholar
• 3 Andrews DW, Faroozan R, Yang BP, Hudes RS, Werner-Wasik M, Kim SM, Sergott RC, Savino PJ, Shields J, Shields C, Downes MB, Simeone FA, Goldman HW, Curran WJ. Fractionated stereotactic radiotherapy for the treatment of optic nerve sheath meningiomas: preliminary observations of 33 optic nerves in 30 patients with historical comparison to observation with or without prior surgery.  Neurosurgery. 2002;  51 ((4)) 890-904
  CrossrefPubMedGoogle Scholar
• 4 Becker G, Jeremic B, Pitz S, Buchgeister M, Wilhelm H, Schiefer U, Paulsen F, Zrenner E, Bamberg M. Stereotactic fractionated radiotherapy in patients with optic nerve sheath meningioma.  Int J Radiat Oncol Biol Phys. 2002;  54 ((5)) 1422-1429
  CrossrefPubMedGoogle Scholar
• 5 Beks JWF, Windt HL de. The recurrence of supratentorial meningiomas after surgery.  Acta Neurochir. 1988;  95 3-5
  CrossrefPubMedGoogle Scholar
• 6 Chang SD, Adler JR, Martin DP. LINAC radiosurgery for cavernous sinus meningiomas.  Stereotact Funct Neurosurg. 1998;  71 ((1)) 43-50
  CrossrefPubMedGoogle Scholar
• 7 Chen JC, Giannotta SL, Yu C, Petrovich Z, Levy ML, Apuzzo ML. Radiosurgical management of benign cavernous sinus tumors: dose profiles and acute complications.  Neurosurgery. 2001;  48 ((5)) 1022-1032
  CrossrefPubMedGoogle Scholar
• 8 Cusimano MD, Sekhar LN, Sen CN. The results of surgery for benign tumors of the cavernous sinus.  Neurosurgery. 1995;  37 1-10
  PubMedGoogle Scholar
• 9 De Jesus O, Sekhar LN, Parikh HK, Wright DC, Wagner DP. Long-term follow up of patients with meningiomas involving the cavernous sinus: recurrence, progression and quality of life.  Neurosurgery. 1996;  39 915-920
  PubMedGoogle Scholar
• 10 Monte F De, Smith HK, Al-Mefty O. Outcome of aggressive removal of cavernous sinus meningiomas.  J Neurosurg. 1994;  81 245-251
  CrossrefPubMedGoogle Scholar
• 11 Debus J, Wuendrich M, Pirzkall A, Hoess A, Schlegel W, Zuna I, Engenhart-Cabillic R, Wannenmacher M. High efficacy of fractionated stereotactic radiotherapy of large base-of-skull meningiomas: long-term results.  J Clin Oncol. 2001;  19 ((15)) 3547-3557
  PubMedGoogle Scholar
• 12 Duchstein S, Gademann G, Peters B. Early and late effects of local high dose radiotherapy of the brain on memory and attention.  Strahlenther Onkol. 2003;  179 ((7)) 441-451
  PubMedGoogle Scholar
• 13 Dufour H, Muracciole X, Metellus P, Regis J, Chinot O, Grisoli F. Long-term tumor control and functional outcome in patients with cavernous sinus meningiomas treated by radiotherapy with or without previous surgery: is there an alternative to aggressive tumor removal?.  Neurosurgery. 2001;  48 ((2)) 285-296
  CrossrefPubMedGoogle Scholar
• 14 Eustacchio S, Trummer M, Fuchs I, Schrottner O, Sutter B, Pendl G. Preservation of cranial nerve function following gamma knife radiosurgery for benign skull base meningiomas: experience in 121 patients with follow-up of 5 to 9.8 years.  Acta Neurochir. 2002;  84 71-76
  PubMedGoogle Scholar
• 15 Gademann G, Schlegel W, Burkelbach J, Laier C, Behrens S, Brieger S, Wannenmacher M. Three-dimensional radiation planning.  Studies on clinical integration. Strahlenther Onkol. 1993;  169 ((3)) 159-167
  PubMedGoogle Scholar
• 16 Gill SS, Thomas DG, Warrington AP, Brada M. Relocatable frame for stereotactic external beam radiotherapy.  Int J Radiat Oncol Biol Phys. 1991;  20 ((3)) 599-603
  PubMedGoogle Scholar
• 17 Goldsmith BJ, Wara WM, Wilson CB, Larson DA. Postoperative irradiation for subtotally resected meningiomas. A retrospective analysis of 140 patients treated from 1967 to 1990.  J Neurosurg. 1994;  80 ((2)) 195-201
  CrossrefPubMedGoogle Scholar
• 18 Gross MW, Spahn U, Engenhart-Cabillic R. Assessment of the accuracy of a conventional simulation for radiotherapy of head and skull base tumours.  Technol Cancer Res Treatment. 2003;  2 345-351
  PubMedGoogle Scholar
• 19 Hakim R, Alexander 3rd E, Loeffler JS, Shrieve DC, Wen P, Fallon MP, Stieg PE. Black PM: Results of linear accelerator-based radiosurgery for intracranial meningiomas.  Neurosurgery. 1998;  42 ((3)) 446-454
  PubMedGoogle Scholar
• 20 Hamm KD, Surber G, Schmücking M, Wurm RE, Aschenbach R, Kleinert G, Niesen A, Baum RP. Stereotactic radiation treatment planning and follow-up studies involving fused multimodality imaging.  J Neurosurg. 2004;  101 ((Suppl 3)) 325-333
  PubMedGoogle Scholar
• 21 Jalali R, Loughrey C, Baumert B, Perks J, Warrington AP, Traish D, Ashley S, Brada M. High precision focused irradiation in the form of fractionated stereotactic conformal radiotherapy (SCRT) for benign meningiomas predominantly in the skull base location.  Clin Oncol (R Coll Radiol). 2002;  14 ((2)) 103-109
  CrossrefPubMedGoogle Scholar
• 22 Karger CP, Jakel O, Debus J, Kuhn S, Hartmann GH. Three-dimensional accuracy and interfractional reproducibility of patient fixation and positioning using a stereotactic head mask system.  Int J Radiat Oncol Biol Phys. 2001;  49 ((5)) 1493-1504
  CrossrefPubMedGoogle Scholar
• 23 Lee JY, Niranjan A, MacInerney J, Kondziolka D, Flickinger JC, Lunsford LD. Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas.  J Neurosurg. 2002;  97 ((1)) 65-72
  CrossrefPubMedGoogle Scholar
• 24 LENT SOMA tables . Radiother Oncol. 1995;  35 ((1)) 17-60
  CrossrefPubMed
• 25 Liscak R, Simonova G, Vymazal J, Janouskova L, Vladyka V. Gamma knife radiosurgery of meningiomas in the cavernous sinus region.  Acta Neurochir. 1999;  141 ((5)) 473-480
  CrossrefPubMedGoogle Scholar
• 26 Lo SS, Cho KH, Hall WA, Kossow RJ, Hernandez WL, MacCollow KK, Gerbi BJ, Higgins PD, Lee CK, Dusenbery KE. Single dose versus fractionated stereotactic radiotherapy for meningiomas.  Can J Neurol Sci. 2002;  29 ((3)) 240-248
  PubMedGoogle Scholar
• 27 Maire JP, Caudry M, Guerin J, Celerier C, San Galli F, Cuasse N, Trouette R, Dautheribes M. Fractionated radiation therapy in the treatment of intracranial meningiomas: local control, functional efficacy, and tolerance in 91 patients.  Int J Radiat Oncol Biol Phys. 1995;  33 ((2)) 315-321
  CrossrefPubMedGoogle Scholar
• 28 Nicolato A, Foroni R, Alessandrini F, Maluta S, Bricolo A, Gerosa M. The role of gamma knife radiosurgery in the management of cavernous sinus meningiomas.  Int J Radiat Oncol Biol Phys. 2002;  53 ((4)) 992-1000
  CrossrefPubMedGoogle Scholar
• 29 O’Sullivan MG, Loveren HR, Tew JM. The surgical resectability of meningiomas of the cavernous sinus.  Neurosurgery. 1997;  40 238-247
  CrossrefPubMedGoogle Scholar
• 30 Pan DH, Guo WY, Chang YC, Chung WY, Shiau CY, Wang LW, Wu SM. The effectiveness and factors related to treatment results of gamma knife radiosurgery for meningiomas.  Stereotact Funct Neurosurg. 1998;  70 ((Suppl. 1)) 19-32
  PubMedGoogle Scholar
• 31 Parsons JT, Bova FJ, Fitzgerald CR. Radiation optic neuropathy after megavoltage external-beam irradiation: Analysis of time-dose factors.  Int J Radiat Oncol Biol Phys. 1994;  30 755-763
  PubMedGoogle Scholar
• 32 Pollock BE, Stafford SL, Utter A, Giannini C, Schreiner SA. Stereotactic radiosurgery provides equivalent tumor control to Simpson Grade 1 resection for patients with small- to medium-size meningiomas.  Int J Radiat Oncol Biol Phys. 2003;  55 ((4)) 1000-1005
  CrossrefPubMedGoogle Scholar
• 33 Rubin P, Constine LS, Fajardo LF, Phillips TL, Wasserman TH. RTOG Late Effects Working Group . Overview. Late Effects of Normal Tissues (LENT) scoring system.  Int J Radiat Oncol Biol Phys. 1995;  31 ((5)) 1041-1042
  CrossrefPubMedGoogle Scholar
• 34 Seegenschmiedt MH. Interdisciplinary documentation of treatment side effects in oncology.  Present status and perspectives. Strahlenther Onkol. 1998;  174 ((Suppl 3)) 25-29
  CrossrefPubMedGoogle Scholar
• 35 Shafron DH, Friedman WA, Buatti JM, Bova FJ, Mendenhall WM. Linac radiosurgery for benign meningiomas.  Int J Radiat Oncol Biol Phys. 1999;  43 ((2)) 321-327
  PubMedGoogle Scholar
• 36 Shrieve DC, Hazard L, Boucher K, Jensen RL. Dose fractionation in stereotactic radiotherapy for parasellar meningiomas: radiobiological considerations of efficacy and optic nerve tolerance.  J Neurosurg. 2004;  101 ((Suppl 3)) 390-395
  PubMedGoogle Scholar
• 37 Spiegelmann R, Nissim O, Menhel J, Alezra D, Pfeffer MR. Linear accelerator radiosurgery for meningiomas in and around the cavernous sinus.  Neurosurgery. 2002;  51 ((6)) 1373-1380
  CrossrefPubMedGoogle Scholar
• 38 Stafford SL, Pollock BE, Foote RL, Link MJ, Gorman DA, Schomberg PJ, Leavitt JA. Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients.  Neurosurgery. 2001;  49 ((5)) 1029-1037
  CrossrefPubMedGoogle Scholar
• 39 Stafford SL, Pollock BE, Leavitt JA, Foote RL, Brown PD, Link MJ, Gormann DA, Schomberg PJ. A study on the radiation tolerance of the optic nerves and chiasm after stereotactic radiosurgery.  Int J Radiat Oncol Biol Phys. 2003;  55 ((5)) 1177-1181
  PubMedGoogle Scholar
• 40 Tome WA, Mehta MP, Meeks SL, Buatti JM. Fractionated stereotactic radiotherapy: a short review.  Technol Cancer Res Treat. 2002;  1 ((3)) 153-172
  PubMedGoogle Scholar
• 41 Havenbergh T Van, Carvalho G, Tatagiba M, Plets C, Samii M. Natural history of petroclival meningiomas.  Neurosurgery. 2003;  52 ((1)) 55-62
  CrossrefPubMedGoogle Scholar
• 42 Verellen D, Linthout N, Bel A, Soete G, Berge D van den, D'Haens J, Storme G. Assessment of the uncertainties in dose delivery of a commercial system for linac-based stereotactic radiosurgery.  Int J Radiat Oncol Biol Phys. 1999;  44 ((2)) 421-433
  CrossrefPubMedGoogle Scholar
• 43 Villavicencio AT, Black PM, Shrieve DC, Fallon MP, Alexander E, Loeffler JS. Linac radiosurgery for skull base meningiomas.  Acta Neurochir. 2001;  143 ((11)) 1141-1152
  CrossrefPubMedGoogle Scholar
• 44 Zimmermann JS, Feldmann HJ, Dorr W. The impact of acute radiation morbidity on therapeutic outcome.  Strahlenther Onkol. 1998;  174 ((Suppl 3)) 1-3
  PubMedGoogle Scholar
• 45 Zimmermann JS, Seegenschmiedt MH, Niehoff P, Galalae R, Kimmig B. Topographic documentation of acute radiation morbidity.  Strahlenther Onkol. 1998;  174 ((Suppl 3)) 30-36
  PubMedGoogle Scholar

Correspondence

PD Dr. K. Hamm

Abteilung für stereotaktische Neurochirurgie und Radiochirurgie

HELIOS Klinikum Erfurt

Nordhäuser Str. 74

99089 Erfurt

Germany

Phone: +361/781 67 18

Fax: +361/781 67 19

Email: khamm@erfurt.helios-kliniken.de