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Oh J, Patel S, Schlosser MP, Arifin AJ, Oliveira C, Charpentier AM, Tsang DS. Pediatric CNS Radiation Oncology: Recent Developments and Novel Techniques. Curr Oncol 2025; 32:180. [PMID: 40136384 PMCID: PMC11941344 DOI: 10.3390/curroncol32030180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2025] [Revised: 03/11/2025] [Accepted: 03/12/2025] [Indexed: 03/27/2025] Open
Abstract
Radiation therapy (RT) is a cornerstone in the management of pediatric central nervous system (CNS) tumors. Recent advancements in RT delivery and techniques aim to enhance therapeutic effectiveness while minimizing both acute and long-term complications associated with pediatric brain RT. This paper highlights innovative developments in the field, including the clinical indications, benefits, and challenges of proton therapy and stereotactic radiotherapy. The ongoing refinement of risk-adapted RT volumes is highlighted, with examples of newly proposed germinoma RT volumes and hippocampal-sparing RT. Additionally, emerging experimental approaches, including FLASH therapy and theranostics, are also discussed as promising future directions. Further prospective, multi-institutional collaborative studies are essential to validate and expand upon the benefits outlined in this review.
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Affiliation(s)
- Justin Oh
- BC Cancer—Vancouver, Vancouver, BC V5Y 4E6, Canada
| | - Samir Patel
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada;
| | | | | | - Carol Oliveira
- McGill University Health Centre, Montreal, QC H4A 0B1, Canada;
| | | | - Derek S. Tsang
- Princess Margaret Cancer Centre, Toronto, ON M5G 2C4, Canada;
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Murphy ES, Sahgal A, Regis J, Levivier M, Fariselli L, Gorgulho A, Ma L, Pollock B, Yomo S, Sheehan J, Paddick I, Suh JH, Saxena A, Ahmed MA, Kotecha R. Pediatric cranial stereotactic radiosurgery: Meta-analysis and international stereotactic radiosurgery society practice guidelines. Neuro Oncol 2025; 27:517-532. [PMID: 39390948 PMCID: PMC11812027 DOI: 10.1093/neuonc/noae204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND There are limited data on the use of stereotactic radiosurgery (SRS) for pediatric patients. The aim of this systematic review was to summarize indications and outcomes specific to pediatric cranial SRS to inform consensus guidelines on behalf of the International Stereotactic Radiosurgery Society. METHODS A systematic review, using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses, analyzed English-language articles on SRS, published between 1989 and 2021, that included outcomes for at least 5 pediatric patients. MEDLINE database terms included tumor types and locations, and radiosurgical and age-specific terms. We excluded nonclinical reports, expert opinions, commentaries, and review articles. Meta-regressions for associations with local control were performed for medulloblastoma, craniopharyngioma, ependymoma, glioma, and arteriovenous malformation (AVM). RESULTS Of the 113 articles identified for review, 68 met the inclusion criteria. These articles described approximately 400 pediatric patients with benign and malignant brain tumors and 5119 with AVMs who underwent cranial SRS. The rates of local control for benign tumors, malignant tumors, and AVMs were 89% (95% CI, 82%-95%), 71% (95% CI, 59%-82%), and 65% (95% CI, 60%-69%), respectively. No significant associations were identified for local control with the patient-, tumor-, or treatment-related variables. CONCLUSIONS This review is the first to summarize outcomes specific to SRS for pediatric brain tumors and AVMs. Although data reporting is limited for pediatric patients, SRS appears to provide acceptable rates of local control. We present ISRS consensus guidelines to inform the judicious use of cranial SRS for pediatric patients.
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Affiliation(s)
- Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Jean Regis
- Department of Functional Neurosurgery, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Center Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Laura Fariselli
- Department of Neurosurgery, Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Milan, Italy
| | - Alessandra Gorgulho
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, São Paulo, Brazil
- D’Or Institute for Research and Education, São Paulo, Brazil
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Bruce Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anshul Saxena
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
| | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
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Düzkalir AH, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Martínez Moreno N, Martínez Álvarez R, Mathieu D, Niranjan A, Lunsford LD, Wei Z, Shanahan RM, Liscak R, May J, Dono A, Blanco AI, Esquenazi Y, Dayawansa S, Sheehan J, Tripathi M, Shepard MJ, Wegner RE, Upadhyay R, Palmer JD, Peker S. Pleomorphic Xanthoastrocytoma: Multi-Institutional Evaluation of Stereotactic Radiosurgery. Neurosurgery 2025; 96:416-425. [PMID: 38940575 DOI: 10.1227/neu.0000000000003083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/20/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pleomorphic xanthoastrocytoma (PXA) is a rare low-grade glial tumor primarily affecting young individuals. Surgery is the primary treatment option; however, managing residual/recurrent tumors remains uncertain. This international multi-institutional study retrospectively assessed the use of stereotactic radiosurgery (SRS) for PXA. METHODS A total of 36 PXA patients (53 tumors) treated at 11 institutions between 1996 and 2023 were analyzed. Data included demographics, clinical variables, SRS parameters, tumor control, and clinical outcomes. Kaplan-Meier estimates summarized the local control (LC), progression-free survival, and overall survival (OS). Secondary end points addressed adverse radiation effects and the risk of malignant transformation. Cox regression analysis was used. RESULTS A total of 38 tumors were grade 2, and 15 tumors were grade 3. Nine patients underwent initial gross total resection, and 10 received adjuvant therapy. The main reason for SRS was residual tumors (41.5%). The median follow-up was 34 months (range, 2-324 months). LC was achieved in 77.4% of tumors, with 6-month, 1-year, and 2-year LC estimates at 86.7%, 82.3%, and 77.8%, respectively. Younger age at SRS (hazard ratios [HR] 3.164), absence of peritumoral edema (HR 4.685), and higher marginal dose (HR 6.190) were significantly associated with better LC. OS estimates at 1, 2, and 5 years were 86%, 74%, and 49.3%, respectively, with a median OS of 44 months. Four patients died due to disease progression. Radiological adverse radiation effects included edema (n = 8) and hemorrhagic change (n = 1). One grade 3 PXA transformed into glioblastoma 13 months after SRS. CONCLUSION SRS offers promising outcomes for PXA management, providing effective LC, reasonable progression-free survival, and minimal adverse events.
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Affiliation(s)
- Ali Haluk Düzkalir
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
- Department of Neurosurgery, Gamma Knife Center, Koc University Hospital, Istanbul , Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Benha University, Benha , Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Clinical Oncology, Ain Shams University, Cairo , Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo , Egypt
| | | | | | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Regan M Shanahan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Antonio Dono
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Angel I Blanco
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Samantha Dayawansa
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Matthew J Shepard
- Department of Neurosurgery, Allegheny Health Network Cancer Institute, Pittsburgh , Pennsylvania , USA
| | - Rodney E Wegner
- Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh , Pennsylvania , USA
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The James Cancer Center, Ohio State University, Columbus , Ohio , USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Center, Ohio State University, Columbus , Ohio , USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
- Department of Neurosurgery, Gamma Knife Center, Koc University Hospital, Istanbul , Turkey
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Liang Q, Wu Z, Zhu S, Du Y, Cheng Z, Chen Y, Lin F, Wang J. A bibliometric analysis of research trends and hotspots of pilocytic astrocytoma from 2004 to 2023. Neurosurg Rev 2024; 48:3. [PMID: 39724457 DOI: 10.1007/s10143-024-03139-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 11/02/2024] [Accepted: 11/30/2024] [Indexed: 12/28/2024]
Abstract
Pilocytic astrocytoma (PA) is a WHO grade I neoplasm with a favorable prognosis. It is the most common pediatric benign tumor. Recently, PA has attracted more and more attention and discussion from scholars. The aim of this study is to comprehensively generalize the evolution of this field over the past two decades through bibliometric analysis and to predict future research trends and hotspots. The literature over the last two decades (2004-2023) related to PA was obtained from the Web of Science Core Collection (WoSCC) database. Bibliometric analyses were conducted based on the following aspects: (1) Annual publication trends; (2) Publications, citations/co-citations of different countries/institutions/journals/authors; (3) the map of Bradford's Law and Lotka's Law for core journals and author productivity; (4) Co-occurrence, cluster, thematic map analysis of keywords. All analyses were performed on VOSviewer and R bibliometrix package, and Excel 2024. Our results showed that research on PA displayed a considerable development trend in the past 20 years. The USA had a leading position in terms of scientific outputs and collaborations. Meanwhile, German Cancer Research Center contributed the most publications. Child's Nervous System had the highest number of publications and Acta Neuropathologica was the most co-cited journal on this subject. Gutmann, D.H. and Louis, D.N. were the authors with the most articles and co-citations in this field. The research emphases were molecular mechanisms, neurofibromatosis, pilomyxoid astrocytoma, differential diagnosis, and therapy. We systematically analyzed the literature on PA from a bibliometric perspective. The demonstrated results of the knowledge mapping would provide valuable insights into the global research landscape.
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Affiliation(s)
- Qingtian Liang
- Department of Neurosurgery and Neuro-Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zuqing Wu
- Department of Neurosurgery and Neuro-Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Sihan Zhu
- University Hospital Ludwig Maximilian University Munich, 81377, Munich, Germany
| | - Yizhi Du
- Department of Neurosurgery and Neuro-Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zhuqing Cheng
- University Hospital Ludwig Maximilian University Munich, 81377, Munich, Germany
| | - Yinsheng Chen
- Department of Neurosurgery and Neuro-Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Fuhua Lin
- Department of Neurosurgery and Neuro-Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China.
| | - Jian Wang
- Department of Neurosurgery and Neuro-Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China.
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Hafez RFA, Fahmy OM, Hassan HT, Ganz JC. Gamma Knife Radiosurgery for symptomatic eloquently deep-seated cystic pilocytic astrocytoma mural nodules: Retrospective case series of effective outcomes. Acta Neurochir (Wien) 2024; 166:466. [PMID: 39565484 DOI: 10.1007/s00701-024-06366-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Accepted: 11/15/2024] [Indexed: 11/21/2024]
Abstract
BACKGROUND Although most pilocytic astrocytomas grow slowly, their progression in critical sites such as the brainstem or hypothalamus may prove fatal much more rapidly. Cystic progression may be more problematic than solid tumor. Patients with progressive cystic PAs located in eloquent deep areas of the brain are the best candidates for stereotactic radiosurgery. OBJECTIVE This retrospective case series aims to present the effective outcomes obtained from GKRS, targeting the mural nodules of symptomatic eloquently deep-seated cystic PAs in 9 consecutive patients treated at the IMC Gamma Knife Centre in Cairo, Egypt, between 2003 and 2021. PATIENT AND METHODS The median follow-up period was 84 months (range 24-240 months). The median treated mural nodule volume was 1.25 cm3 (range 0.32-1.97 cm3), treated with a median peripheral prescription dose of 12 Gy and a median maximum dose of 24 Gy. The median cyst volume in treated patients was 7.64cm3(range 1.66-40.6cm3). RESULTS At the last follow-up, 7 out of 9 patients (78%) achieved tumor control (marked reduction > 50% of the entire tumor volume in 6 patients and moderate tumor reduction < 50% in one patient) in addition to clinical improvement. The median time of confirmed tumor reduction was 18 months (range 12-32 months). Two patients reported progression of the treated tumor. The overall tumor control rates at 2, 5, and 7 years of follow-up were 88.9%, 78%, and 78%, respectively. CONCLUSION The encouraging results of this series indicate that limiting the GKRS to the mural nodule of eloquently deep-seated cystic PAs may be a practical and effective pattern in the salvage of its treatment. Our data do not support radiation for extensive, large symptomatic cysts in deep-seated cystic PA or patients where microsurgical removal is feasible.
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Affiliation(s)
- Raef F A Hafez
- Department of Neurosurgery and Gamma Knife Radiosurgery, International Medical Center (IMC), Cairo, Egypt.
| | - Osama M Fahmy
- Department of Neurosurgery and Gamma Knife Radiosurgery, International Medical Center (IMC), Cairo, Egypt
| | - Hamdy T Hassan
- Department of Neurosurgery and Gamma Knife Radiosurgery, International Medical Center (IMC), Cairo, Egypt
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Kilic Durankus N, Samanci Y, Düzkalir AH, Peker S. Unveiling the Efficacy of Gamma Knife Radiosurgery for Tectal Plate Gliomas. Neurosurgery 2024; 94:780-787. [PMID: 37955438 DOI: 10.1227/neu.0000000000002754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/21/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Tectal plate gliomas (TPGs) are midbrain tumors that grow slowly and have a benign clinical course. Most TPGs are low-grade astrocytomas, but they can encompass various histological tumor types. Gamma Knife radiosurgery (GKRS) is being explored as a potentially safe and effective treatment option for TPGs, although research in this area is limited. This study aims to evaluate GKRS's efficacy and safety in patients with TPG and provide a comprehensive review of existing literature on the topic. METHODS This retrospective, single-center study included 48 patients with consecutive TPG who underwent GKRS between September 2005 and June 2022. Patients diagnosed with TPGs based on radiological or tissue-based criteria and who had a minimum follow-up period of 12 months were eligible for inclusion. The primary end points were local control and the absence of GKRS-associated or tumor-associated mortality and morbidity. RESULTS During a median follow-up of 28.5 months (range, 12-128), the radiological assessment showed tumor control in all cases, with 16.7% achieving a complete response and 68.8% achieving a partial response. Pseudoprogression occurred in 6.2% of cases, with onset ranging from 3 to 8 months. Clinical outcomes revealed no permanent neurological deterioration, with symptoms improving in 14.6% of patients and remaining stable in the others. One patient in the pseudoprogression group experienced transient Parinaud syndrome. One patient died during follow-up because of unrelated causes. The mean survival time after GKRS was 123.7 months. None of the clinical, radiological, or radiosurgical variables showed a correlation with partial/complete response, clinical improvement, or overall survival. CONCLUSION There is limited research available on the management of TPGs, and this study presents the largest patient cohort treated with GKRS, along with a substantial follow-up duration. Despite its limitations, this study demonstrates the efficacy and low-risk profile of GKRS for TPGs.
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Affiliation(s)
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
- Department of Neurosurgery, Gamma Knife Center, Koc University Hospital, Istanbul , Turkey
| | - Ali Haluk Düzkalir
- Department of Neurosurgery, Gamma Knife Center, Koc University Hospital, Istanbul , Turkey
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
- Department of Neurosurgery, Gamma Knife Center, Koc University Hospital, Istanbul , Turkey
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Liu KX, Haas-Kogan DA, Elhalawani H. Radiotherapy for Primary Pediatric Central Nervous System Malignancies: Current Treatment Paradigms and Future Directions. Pediatr Neurosurg 2023; 58:356-366. [PMID: 37703864 DOI: 10.1159/000533777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Central nervous system tumors are the most common solid tumors in childhood. Treatment paradigms for pediatric central nervous system malignancies depend on elements including tumor histology, age of patient, and stage of disease. Radiotherapy is an important modality of treatment for many pediatric central nervous system malignancies. SUMMARY While radiation contributes to excellent overall survival rates for many patients, radiation also carries significant risks of long-term side effects including neurocognitive decline, hearing loss, growth impairment, neuroendocrine dysfunction, strokes, and secondary malignancies. In recent decades, clinical trials have demonstrated that with better imaging and staging along with more sophisticated radiation planning and treatment set-up verification, smaller treatment volumes can be utilized without decrement in survival. Furthermore, the development of intensity-modulated radiotherapy and proton-beam radiotherapy has greatly improved conformality of radiation. KEY MESSAGES Recent changes in radiation treatment paradigms have decreased risks of short- and long-term toxicity for common histologies and in different age groups. Future studies will continue to develop novel radiation regimens to improve outcomes in aggressive central nervous system tumors, integrate molecular subtypes to tailor radiation treatment, and decrease radiation-associated toxicity for long-term survivors.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Radiosurgery outcomes in infratentorial juvenile pilocytic astrocytomas. J Neurooncol 2023; 162:157-165. [PMID: 36894718 DOI: 10.1007/s11060-023-04277-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To assess survival and neurological outcomes for patients who underwent primary or salvage stereotactic radiosurgery (SRS) for infratentorial juvenile pilocytic astrocytomas (JPA). METHODS Between 1987 and 2022, 44 patients underwent SRS for infratentorial JPA. Twelve patients underwent primary SRS and 32 patients underwent salvage SRS. The median patient age at SRS was 11.6 years (range, 2-84 years). Prior to SRS, 32 patients had symptomatic neurological deficits, with ataxia as the most common symptom in 16 patients. The median tumor volume was 3.22 cc (range, 0.16-26.6 cc) and the median margin dose was 14 Gy (range, 9.6-20 Gy). RESULTS The median follow-up was 10.9 years (range, 0.42-26.58 years). Overall survival (OS) after SRS was 97.7% at 1-year, and 92.5% at 5- and 10-years. Progression free survival (PFS) after SRS was 95.4% at 1-year, 79.0% at 5-years, and 61.4% at 10-years. There is not a significant difference in PFS between primary and salvage SRS patients (p = 0.79). Younger age correlated with improved PFS (HR 0.28, 95% CI 0.063-1.29, p = 0.021). Sixteen patients (50%) had symptomatic improvements while 4 patients (15.6%) had delayed onset of new symptoms related to tumor progression (n = 2) or treatment related complications (n = 2). Tumor volumetric regression or disappearance after radiosurgery was found in 24 patients (54.4%). Twelve patients (27.3%) had delayed tumor progression after SRS. Additional management of tumor progression included repeat surgery, repeat SRS, and chemotherapy. CONCLUSIONS SRS was a valuable alternative to initial or repeat resection for deep seated infratentorial JPA patients. We found no survival differences between patients who had primary and salvage SRS.
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Scherschinski L, Jubran JH, Shaftel KA, Furey CG, Farhadi DS, Benner D, Hendricks BK, Smith KA. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Management of Low-Grade Gliomas and Radiation Necrosis: A Single-Institution Case Series. Brain Sci 2022; 12:brainsci12121627. [PMID: 36552087 PMCID: PMC9775146 DOI: 10.3390/brainsci12121627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) has emerged as a minimally invasive treatment modality for ablation of low-grade glioma (LGG) and radiation necrosis (RN). OBJECTIVE To evaluate the efficacy, safety, and survival outcomes of patients with radiographically presumed recurrent or newly diagnosed LGG and RN treated with LITT. METHODS The neuro-oncological database of a quaternary center was reviewed for all patients who underwent LITT for management of LGG between 1 January 2013 and 31 December 2020. Clinical data including demographics, lesion characteristics, and clinical and radiographic outcomes were collected. Kaplan-Meier analyses comprised overall survival (OS) and progression-free survival (PFS). RESULTS Nine patients (7 men, 2 women; mean [SD] age 50 [16] years) were included. Patients underwent LITT at a mean (SD) of 11.6 (8.5) years after diagnosis. Two (22%) patients had new lesions on radiographic imaging without prior treatment. In the other 7 patients, all (78%) had surgical resection, 6 (67%) had intensity-modulated radiation therapy and chemotherapy, respectively, and 4 (44%) had stereotactic radiosurgery. Two (22%) patients had lesions that were wild-type IDH1 status. Volumetric assessment of preoperative T1-weighted contrast-enhancing and T2-weighted fluid-attenuated inversion recovery (FLAIR) sequences yielded mean (SD) lesion volumes of 4.1 (6.5) cm3 and 26.7 (27.9) cm3, respectively. Three (33%) patients had evidence of radiographic progression after LITT. The pooled median (IQR) PFS for the cohort was 52 (56) months, median (IQR) OS after diagnosis was 183 (72) months, and median (IQR) OS after LITT was 52 (60) months. At the time of the study, 2 (22%) patients were deceased. CONCLUSIONS LITT is a safe and effective treatment option for management of LGG and RN, however, there may be increased risk of permanent complications with treatment of deep-seated subcortical lesions.
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Affiliation(s)
- Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Correspondence: ; Tel.: +1-602-693-5883
| | - Jubran H. Jubran
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Kelly A. Shaftel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Charuta G. Furey
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Dara S. Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Benjamin K. Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Kris A. Smith
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
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Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, Gumustepe E, Ozcan F, Colak O, Gursoy AT, Dursun CU, Tugcu AO, Dogru GD, Arslan R, Elcim Y, Gundem E, Dirican B, Beyzadeoglu M. Concise review of radiosurgery for contemporary management of pilocytic astrocytomas in children and adults. World J Exp Med 2022; 12:36-43. [PMID: 35765513 PMCID: PMC9168785 DOI: 10.5493/wjem.v12.i3.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 03/09/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
Pilocytic astrocytoma (PA) may be seen in both adults and children as a distinct histologic and biologic subset of low-grade glioma. Surgery is the principal treatment for the management of PAs; however, selected patients may benefit from irradiation particularly in the setting of inoperability, incomplete resection, or recurrent disease. While conventionally fractionated radiation therapy has been traditionally utilized for radiotherapeutic management, stereotactic irradiation strategies have been introduced more recently to improve the toxicity profile of radiation delivery without compromising tumor control. PAs may be suitable for radiosurgical management due to their typical appearance as well circumscribed lesions. Focused and precise targeting of these well-defined lesions under stereotactic immobilization and image guidance may offer great potential for achieving an improved therapeutic ratio by virtue of radiosurgical techniques. Given the high conformality along with steep dose gradients around the target volume allowing for reduced normal tissue exposure, radiosurgery may be considered a viable modality of radiotherapeutic management. Another advantage of radiosurgery may be the completion of therapy in a usually shorter overall treatment time, which may be particularly well suited for children with requirement of anesthesia during irradiation. Several studies have addressed the utility of radiosurgery particularly as an adjuvant or salvage treatment modality for PA. Nevertheless, despite the growing body of evidence supporting the use of radiosurgery, there is need for a high level of evidence to dictate treatment decisions and establish its optimal role in the management of PA. Herein, we provide a concise review of radiosurgery for PA in light of the literature.
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Affiliation(s)
- Omer Sager
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Esra Gumustepe
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Fatih Ozcan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Onurhan Colak
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Ahmet Tarik Gursoy
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Cemal Ugur Dursun
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Ahmet Oguz Tugcu
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Galip Dogukan Dogru
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Rukiyye Arslan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Yelda Elcim
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Esin Gundem
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Bahar Dirican
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 0090, Turkey
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11
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Elwatidy SM, Ahmed J, Bawazir MH, Alnasser A, Abanumy J, Al Shammari A, Alduhaish A, Malik SH, Elwatidy HS. Outcome of Childhood Cerebellar Pilocytic Astrocytoma: A Series With 20 Years of Follow Up. Cureus 2022; 14:e22258. [PMID: 35350495 PMCID: PMC8933261 DOI: 10.7759/cureus.22258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Cerebellar pilocytic astrocytoma (PCA) is one of the few CNS tumors that can be cured with gross-total removal (GTR). In this series, we had 39 patients diagnosed with cerebellar PCA, 27 patients (70%) had GTR, and mean follow-up period was 62 months with no tumor recurrence. Objective: To assess the long-term outcome of childhood cerebellar PCA treated at our institute during the period 2000-2020 and to highlight our surgical protocol. Methodology: Retrospective review of all patients under 18 years of age who were diagnosed with cerebellar PCA and had surgical excision between 2000 and 2020 at the Medical City of King Saud University. Results: The study included 39 patients: 17 males and 22 females, the mean age was 8.4 years. Radiologically, the tumor was solid in eight patients, cystic in 15 patients, and mixed components were found in 16 patients. The lesion was located in the right cerebellar hemisphere in 12 patients, left cerebellar hemisphere in five patients, and midline 22 patients. The tumor size ranged from 2 to 7 cm in its greatest diameter, it was <5 cm in 13 patients and >5 cm in 26 patients. Thirty-one patients had preoperative hydrocephalus. GTR of the tumor was achieved in 27 patients and subtotal resection (STR) was done in 12 patients, 18 patients required permanent ventriculoperitoneal (V-P) shunt, and five patients had postoperative radiotherapy. Postoperative complications included infection in two patients, cerebellar mutism in two patients, and significant neurologic disability in four patients. The duration of follow-up ranged from 0 to 240 months (mean follow-up period: 62.0 months). The outcome at 10 years was good in 30 patients, fair in four patients, poor in four patients, and one patient died. Recurrence was documented in nine patients, seven of them had GTR and two had STR. Conclusion: GTR, if achievable, is curative for childhood cerebellar PCA. Many posterior fossa surgical complications could be avoided with watertight dural closure. Although new dural substitutes are available we prefer using autologous grafts (pericranium). It is easy to harvest pericranial graft from the external ventricular drain (EVD) site. The insertion of EVD synchronously with GTR of the tumor and gradual weaning of EVD could avoid the insertion of V-P shunt.
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12
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Ganz JC. Low grade gliomas. PROGRESS IN BRAIN RESEARCH 2022; 268:271-277. [PMID: 35074085 DOI: 10.1016/bs.pbr.2021.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Low grade gliomas concern grade I and grade II tumors. The only grade one tumor is the pilocytic astrocytoma. This is a well-defined tumor with characteristic histology, often accompanied by a cyst. GKNS has been used in surgically inaccessible tumors since 1994. More recently it has been demonstrated that the tumors are more treatment resistant in adults than in children. Grade II tumors include oligodendrogliomas and grade II diffuse astrocytomas. The standard treatment for oligodendrogliomas us total removal followed by fractionated radiotherapy. GKNS has been shown to be of benefit in smaller tumors which have not responded to other treatment. It may also have a role as an ancillary treatment in smaller Grade II astrocytomas.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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13
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Jumah F, Abou-Al-Shaar H, Mallela AN, Wiley CA, Lunsford LD. Gamma Knife Radiosurgery in the Management of Hypothalamic Glioma: A Case Report with Long-Term Follow-Up. Pediatr Neurosurg 2022; 57:118-126. [PMID: 34969032 DOI: 10.1159/000521732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Optic pathway/hypothalamic gliomas are rare pediatric brain tumors. The management paradigm for these challenging tumors includes chemotherapy, radiotherapy, or surgical resection, but the optimal management strategy remains elusive. Gamma knife radiosurgery (GKRS) has emerged as a promising treatment for such lesions as documented by a small number of cases in the literature. CASE PRESENTATION We present a rare case of hypothalamic glioma in a 13-year-old girl who was referred to our service due to growth of an incidentally diagnosed hypothalamic lesion following head injury at the age of 8 years. The lesion demonstrated hypointensity on T1- and hyperintensity on T2-weighted imaging without contrast enhancement. Given the growth of the lesion on serial imaging, a stereotactic biopsy was performed demonstrating low-grade glioma. The patient underwent GKRS treatment with a marginal dose of 15 Gy at 50% isodose line for a tumor volume of 2.2 mL. Annual radiological surveillance over the next 17 years demonstrated a gradual shrinkage of the lesion until it completely disappeared. The patient is currently a healthy 31-year-old female without any visual, endocrine, or neurocognitive deficits. CONCLUSION The outcome obtained after extended follow-up in our patient highlights the safety and efficacy of GKRS in the management of hypothalamic gliomas in pediatrics, which in turn can avoid potentially serious complications of surgery in this vulnerable patient population, especially in this sensitive location.
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Affiliation(s)
- Fareed Jumah
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, Rutgers-New Jersey Medical School, New Brunswick, New Jersey, USA,
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arka N Mallela
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Clayton A Wiley
- Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, Colak O, Ozcan F, Gundem E, Elcim Y, Dirican B, Beyzadeoglu M. Concise review of stereotactic irradiation for pediatric glial neoplasms: Current concepts and future directions. World J Methodol 2021; 11:61-74. [PMID: 34026579 PMCID: PMC8127424 DOI: 10.5662/wjm.v11.i3.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
Brain tumors, which are among the most common solid tumors in childhood, remain a leading cause of cancer-related mortality in pediatric population. Gliomas, which may be broadly categorized as low grade glioma and high grade glioma, account for the majority of brain tumors in children. Expectant management, surgery, radiation therapy (RT), chemotherapy, targeted therapy or combinations of these modalities may be used for management of pediatric gliomas. Several patient, tumor and treatment-related characteristics including age, lesion size, grade, location, phenotypic and genotypic features, symptomatology, predicted outcomes and toxicity profile of available therapeutic options should be considered in decision making for optimal treatment. Management of pediatric gliomas poses a formidable challenge to the physicians due to concerns about treatment induced toxicity. Adverse effects of therapy may include neurological deficits, hemiparesis, dysphagia, ataxia, spasticity, endocrine sequelae, neurocognitive and communication impairment, deterioration in quality of life, adverse socioeconomic consequences, and secondary cancers. Nevertheless, improved understanding of molecular pathology and technological advancements may pave the way for progress in management of pediatric glial neoplasms. Multidisciplinary management with close collaboration of disciplines including pediatric oncology, surgery, and radiation oncology is warranted to achieve optimal therapeutic outcomes. In the context of RT, stereotactic irradiation is a viable treatment modality for several central nervous system disorders and brain tumors. Considering the importance of minimizing adverse effects of irradiation, radiosurgery has attracted great attention for clinical applications in both adults and children. Radiosurgical applications offer great potential for improving the toxicity profile of radiation delivery by focused and precise targeting of well-defined tumors under stereotactic immobilization and image guidance. Herein, we provide a concise review of stereotactic irradiation for pediatric glial neoplasms in light of the literature.
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Affiliation(s)
- Omer Sager
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Onurhan Colak
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Fatih Ozcan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Esin Gundem
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Yelda Elcim
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Bahar Dirican
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Ankara 06018, Turkey
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15
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Prasad D, Vern-Gross T, Wolden S. Radiosurgery, reirradiation, and brachytherapy. Pediatr Blood Cancer 2021; 68 Suppl 2:e28531. [PMID: 33818888 DOI: 10.1002/pbc.28531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/05/2022]
Abstract
Radiosurgery and brachytherapy are potentially useful treatment techniques that are sparingly applied in pediatric oncology. They are often used in the setting of reirradiation for recurrent or metastatic tumors. Reirradiation in children with recurrent tumors is complicated by the tolerance of critical organs and the potential risks for overall long-term dose-dependent complications. We review the current literature available in support of reirradiation and the use of radiosurgery and brachytherapy in pediatric patients.
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Affiliation(s)
- Dheerendra Prasad
- Department of Radiation Oncology and Neurosurgery, Roswell Park Comprehensive Cancer Center and Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | | | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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16
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Deora H, Tripathi M, Tewari MK, Ahuja CK, Kumar N, Kaur A, Kamboj P. Role of gamma knife radiosurgery in the management of intracranial gliomas. Neurol India 2021; 68:290-298. [PMID: 32415008 DOI: 10.4103/0028-3886.284356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Gamma knife for gliomas is a relatively obscure treatment modality with few reports and small series available on the same. An extensive search of English Language literature yields no comprehensive reviews of the same. We here, attempt to review the available literature on gamma knife for all types of gliomas: Low grade, High grade, recurrent, and also for pediatric populations. We used keywords such as "Gamma Knife Glioma," "Stereotactic Radiosurgery Glioma," "Gamma Knife," "Adjuvant therapy Glioma" "Recurrent Glioma" on PubMed search engine, and articles were selected with respect to their use of gamma Knife for Gliomas and outcome for the same. These were then analyzed and salient findings were elucidated. This was combined with National Comprehensive Cancer Network guidelines for the same and also included our own initial experience with these tumors. Gamma-knife improved long term survival and quality of life in patients with low grade gliomas. In pediatric low grade gliomas, it may be considered as a treatment modality with a marginal dose of 12-14 Gy, especially in eloquent structures such as brain stem glioma, anterior optic pathway hypothalamic glioma. However, in newly diagnosed high-grade glioma gamma knife radiosurgery (GKRS) is not recommended because of a lack of definitive evidence in tumor control and quality of life. GKRS may find its role in palliative care of recurrent gliomas irrespective of type and grade. Inspite of growing experience with GKRS for gliomas, there is no Level I evidence in support of GKRS, hence better designed randomized controlled trials with long term outcomes are warranted. Although this modality is not a "one size fits all' therapy, it has its moments when chosen correctly and applied wisely. Gliomas being the most common tumors operated in any neurosurgical setting, knowledge about this modality and its application is essential and useful.
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Affiliation(s)
- Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj K Tewari
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Kamal Ahuja
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Kumar
- Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjot Kaur
- Department of Medical Physics, Panjab University, Chandigarh, India
| | - Parwinder Kamboj
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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17
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Fomchenko EI, Reeves BC, Sullivan W, Marks AM, Huttner A, Kahle KT, Erson‐Omay EZ. Dual activating FGFR1 mutations in pediatric pilomyxoid astrocytoma. Mol Genet Genomic Med 2021; 9:e1597. [PMID: 33448156 PMCID: PMC8077124 DOI: 10.1002/mgg3.1597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 11/30/2020] [Accepted: 12/15/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pilomyxoid astrocytomas are an aggressive subtype of astrocytoma, not graded by WHO, frequently located in hypothalamic/chiasmatic region, affecting diencephalic structures, and characterized by shorter survival and high recurrence rates. Pilomyxoid astrocytoma management remains controversial, with pathologic tissue diagnosis and relief of mass effect being the main goals of surgery while avoiding treatment-related morbidity, including vision loss, panhypopituitarism, and hypothalamic dysfunction. Chemotherapy (typically vincristine and carboplatin) in all pediatric patients and radiation therapy in pediatric patients over 5 years of age are used for treatment. METHODS We report clinical presentation, surgical management, and whole exome sequencing results in a pediatric patient with the subtotally resected pilomyxoid astrocytoma. RESULTS We identified two somatic activating missense mutations affecting FGFR1, including FGFR1 p.K656E and FGFR1 p.V561M. While the former is a known hotspot mutation that is both activating and transforming, the latter has been described as a gatekeeper mutation imparting resistance to FGFR inhibitors. Interestingly, both mutations were present with similar variant allele frequency within the tumor. CONCLUSION Similar variant allele frequencies of FGFR1 p.K656E and FGFR1 p.V561M mutations in our patient's tumor suggest that these mutations may have occurred at similar time points. Use of FGFR inhibitors in addition to STAT3 or PI3K/mTOR inhibition may prove a useful strategy in targeting our patient's pilomyxoid astrocytoma.
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Affiliation(s)
| | | | | | - Asher M. Marks
- Department of PediatricsHematology/OncologyYale School of MedicineNew HavenCTUSA
| | - Anita Huttner
- Department of PathologyYale School of MedicineNew HavenCTUSA
| | - Kristopher T. Kahle
- Department of NeurosurgeryYale School of MedicineNew HavenCTUSA
- Centers for Mendelian Genomics and Yale Program on NeurogeneticsYale School of MedicineNew HavenCTUSA
- Department Cellular & Molecular PhysiologyYale School of MedicineNew HavenCTUSA
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18
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Murphy ES, Parsai S, Kano H, Sheehan JP, Martinez-Alvarez R, Martinez-Moreno N, Kondziolka D, Simonova G, Liscak R, Mathieu D, Lee CC, Yang HC, Lee JY, McShane BJ, Fang F, Trifiletti DM, Sharma M, Barnett GH. Outcomes of stereotactic radiosurgery for pilocytic astrocytoma: an international multiinstitutional study. J Neurosurg 2021; 134:162-170. [PMID: 31783364 DOI: 10.3171/2019.9.jns191335] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/13/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The current standard initial therapy for pilocytic astrocytoma is maximal safe resection. Radiation therapy is considered for residual, recurrent, or unresectable pilocytic astrocytomas. However, the optimal radiation strategy has not yet been established. Here, the authors describe the outcomes of stereotactic radiosurgery (SRS) for pilocytic astrocytoma in a large multiinstitutional cohort. METHODS An institutional review board-approved multiinstitutional database of patients treated with Gamma Knife radiosurgery (GKRS) between 1990 and 2016 was queried. Data were gathered from 9 participating International Radiosurgery Research Foundation (IRRF) centers. Patients with a histological diagnosis of pilocytic astrocytoma treated using a single session of GKRS and with at least 6 months of follow-up were included in the analysis. RESULTS A total of 141 patients were analyzed in the study. The median patient age was 14 years (range 2-84 years) at the time of GKRS. The median follow-up was 67.3 months. Thirty-nine percent of patients underwent SRS as the initial therapy, whereas 61% underwent SRS as salvage treatment. The median tumor volume was 3.45 cm3. The tumor location was the brainstem in 30% of cases, with a nonbrainstem location in the remainder. Five- and 10-year overall survival rates at the last follow-up were 95.7% and 92.5%, respectively. Five- and 10-year progression-free survival (PFS) rates were 74.0% and 69.7%, respectively. On univariate analysis, an age < 18 years, tumor volumes < 4.5 cm3, and no prior radiotherapy or chemotherapy were identified as positive prognostic factors for improved PFS. On multivariate analysis, only prior radiotherapy was significant for worse PFS. CONCLUSIONS This represents the largest study of single-session GKRS for pilocytic astrocytoma to date. Favorable long-term PFS and overall survival were observed with GKRS. Further prospective studies should be performed to evaluate appropriate radiosurgery dosing, timing, and sequencing of treatment along with their impact on toxicity and the quality of life of patients with pilocytic astrocytoma.
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Affiliation(s)
- Erin S Murphy
- 1Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
- 13Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland, Ohio
| | - Shireen Parsai
- 1Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Hideyuki Kano
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 3Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Roberto Martinez-Alvarez
- 4Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Nuria Martinez-Moreno
- 4Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Douglas Kondziolka
- 5Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Gabriela Simonova
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - David Mathieu
- 7Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada
| | - Cheng-Chia Lee
- 8Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Huai-Che Yang
- 8Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - John Y Lee
- 9Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan J McShane
- 9Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fang Fang
- 10Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Mayur Sharma
- 12Department of Neurosurgery, University of Louisville, Kentucky; and
| | - Gene H Barnett
- 13Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland, Ohio
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19
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Abstract
Brain tumors constitute the largest source of oncologic mortality in children and low-grade gliomas are among most common pediatric central nervous system tumors. Pediatric low-grade gliomas differ from their counterparts in the adult population in their histopathology, genetics, and standard of care. Over the past decade, an increasingly detailed understanding of the molecular and genetic characteristics of pediatric brain tumors led to tailored therapy directed by integrated phenotypic and genotypic parameters and the availability of an increasing array of molecular-directed therapies. Advances in neuroimaging, conformal radiation therapy, and conventional chemotherapy further improved treatment outcomes. This article reviews the current classification of pediatric low-grade gliomas, their histopathologic and radiographic features, state-of-the-art surgical and adjuvant therapies, and emerging therapies currently under study in clinical trials.
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20
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Liu JS, Foo D, Yeo TT, Ho KH, Nga VDW, Karlsson B. Twenty-three years follow-up after low-dose Gamma Knife surgery of a brainstem juvenile pilocytic astrocytoma: a case report and review of the literature. Childs Nerv Syst 2019; 35:1227-1230. [PMID: 30997566 DOI: 10.1007/s00381-019-04147-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 04/02/2019] [Indexed: 11/25/2022]
Abstract
Juvenile pilocytic astrocytoma (JPA) is a World Health Organization (WHO) grade I tumor that is the commonest to occur in the 0-19 age group, with an excellent prognosis of 96% 10-year survival in pediatric patients. Complete resection is the treatment of choice for JPAs. However, this is not always feasible due to the location of certain tumors, and the management following subtotal resection is controversial. Fractionated radiotherapy, chemotherapy, radiosurgery, and observation have all been used to treat tumor remnants. We report a young patient with good tumor control 23 years following low-dose Gamma Knife surgery (GKS) of a subtotally resected brainstem JPA and recommend that GKS may be a feasible treatment option to achieve long-term tumor control when subtotal resection cannot be achieved, even if the GKS prescription dose must be significantly reduced due to large tumor volume or proximity to critical structures sensitive to radiation.
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Affiliation(s)
- J Sherry Liu
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Denise Foo
- Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Kee Hang Ho
- Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | | | - Bengt Karlsson
- Division of Neurosurgery, National University Hospital, Singapore, Singapore
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21
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Kondziolka D. Current and novel practice of stereotactic radiosurgery. J Neurosurg 2019; 130:1789-1798. [PMID: 31153140 DOI: 10.3171/2019.2.jns181712] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 11/06/2022]
Abstract
Stereotactic radiosurgery emerged as a neurosurgical discipline in order to utilize energy for the manipulation of brain or nerve tissue, with the goal of minimal access and safe and effective care of a spectrum of neurosurgical disorders. Perhaps no other branch of neurosurgery has been so disruptive across the entire discipline of brain tumor care, treatment of vascular disorders, and management of functional problems. Radiosurgery is mainstream, supported by thousands of peer-reviewed outcomes reports. This article reviews current practice with a focus on challenges, emerging trends, and areas of investigation.
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22
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El-Shehaby AMN, Reda WA, Abdel Karim KM, Emad Eldin RM, Nabeel AM. Single-session Gamma Knife radiosurgery for optic pathway/hypothalamic gliomas. J Neurosurg 2018; 125:50-57. [PMID: 27903182 DOI: 10.3171/2016.8.gks161432] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Because of their critical and central location, it is deemed necessary to fractionate when considering irradiating optic pathway/hypothalamic gliomas. Stereotactic fractionated radiotherapy is considered safer when dealing with gliomas in this location. In this study, the safety and efficacy of single-session stereotactic radiosurgery for optic pathway/hypothalamic gliomas were reviewed. METHODS Between December 2004 and June 2014, 22 patients with optic pathway/hypothalamic gliomas were treated by single-session Gamma Knife radiosurgery. Twenty patients were available for follow-up for a minimum of 1 year after treatment. The patients were 5 to 43 years (median 16 years) of age. The tumor volume was 0.15 to 18.2 cm3 (median 3.1 cm3). The prescription dose ranged from 8 to 14 Gy (median 11.5 Gy). RESULTS The mean follow-up period was 43 months. Five tumors involved the optic nerve only, and 15 tumors involved the chiasm/hypothalamus. Two patients died during the follow-up period. The tumors shrank in 12 cases, remained stable in 6 cases, and progressed in 2 cases, thereby making the tumor control rate 90%. Vision remained stable in 12 cases, improved in 6 cases, and worsened in 2 cases in which there was tumor progression. Progression-free survival was 83% at 3 years. CONCLUSIONS The initial results indicate that single-session Gamma Knife radiosurgery is a safe and effective treatment option for optic pathway/hypothalamic gliomas.
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Affiliation(s)
| | - Wael A Reda
- Gamma Knife Center Cairo.,Neurosurgery Department and
| | - Khaled M Abdel Karim
- Gamma Knife Center Cairo.,Clinical Oncology Department, Faculty of Medicine, Ain Shams University
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo.,Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo; and
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo.,Neurosurgery Department, Faculty of Medicine, Benha University, Qalubya, Egypt
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23
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Blionas A, Giakoumettis D, Klonou A, Neromyliotis E, Karydakis P, Themistocleous MS. Paediatric gliomas: diagnosis, molecular biology and management. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:251. [PMID: 30069453 PMCID: PMC6046297 DOI: 10.21037/atm.2018.05.11] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/02/2018] [Indexed: 01/14/2023]
Abstract
Paediatric gliomas represent the most common brain tumour in children. Early diagnosis and treatment greatly improve survival. Histological grade is the most significant classification system affecting treatment planning and prognosis. Paediatric gliomas depend on pathways and genes responsible for mitotic activity and cell proliferation as well as angiogenesis (MAPK, VEGF, EFGR pathways). Symptoms such as focal neurologic deficit or seizures can facilitate diagnosis, but they are not always present and therefore diagnosis is occasionally delayed. Imaging has adequate diagnostic accuracy (surpassing 90%), and novel imaging techniques such as MR spectroscopy and PET increase only slightly this percentage. Low grade gliomas (LGG) can be approached conservatively but most authors suggest surgical excision. High grade gliomas (HGG) are always operated with exception of specific contradictions including butterfly or extensive dominant hemisphere gliomas. Surgical excision is universally followed by radiotherapy and chemotherapy, which slightly increase survival. Inoperable cases can be managed with or without radiosurgery depending on location and size, with adjunctive use of radiotherapy and chemotherapy. Surgical excision must be aggressive and gross total resection (GTR) should be attempted, if possible, since it can triple survival. Radiosurgery is effective on smaller tumours of <2 cm2. Surgical excision is always the treatment of choice, but glioma recurrences, and residual tumours in non-critical locations are candidates for radiosurgery especially if tumour volume is low. Management of recurrences includes surgery, radiosurgery and chemoradiotherapy and it should be individualized according to location and size. In combination with molecular targeted therapeutic schemes, glioma management will be immensely improved in the next years.
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Affiliation(s)
- Alexandros Blionas
- Department of Neurosurgery, G. Gennimatas General Hospital, Athens, Greece
| | - Dimitrios Giakoumettis
- Department of Neurosurgery, University of Athens Medical School, “Evangelismos” General Hospital, Athens, Greece
| | - Alexia Klonou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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24
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Trifiletti DM, Peach MS, Xu Z, Kersh R, Showalter TN, Sheehan JP. Evaluation of outcomes after stereotactic radiosurgery for pilocytic astrocytoma. J Neurooncol 2017; 134:297-302. [PMID: 28567590 DOI: 10.1007/s11060-017-2521-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/29/2017] [Indexed: 12/18/2022]
Abstract
Pilocytic astrocytomas are rare intracranial gliomas that are typically treated with surgical extirpation. Our aim was to report the radiologic and clinical outcomes of patients treated with stereotactic radiosurgery (SRS) for pilocytic astrocytoma in the primary and salvage setting. Patients with pilocytic astrocytoma treated at a single institution with SRS from 1990 to 2015 were reviewed. Patient, disease, and treatment characteristics were collected and overall survival, local control, and toxicity were evaluated. Twenty-eight consecutive patients (12 females and 16 males) with a median age of 17.4 years at SRS were identified. Overall, 46% of patients were treated with SRS as part of the initial treatment course after biopsy or subtotal resection, and the remainder as a salvage therapy. The most common location was the cerebellum (28%) followed by brainstem and basal ganglia (21 and 18%, respectively). Four patients received prior external beam radiation therapy (14%). Median tumor volume was 1.84 cc (0.19-15.94 cc), and 39% had a cystic component at SRS. Prescription dose ranged from 4 to 20 Gy (median 16 Gy) to a median isodose line of 50% (range 30-100%). With a median follow-up of 5.2 years (0.3-17.1 years), all patients remained alive at last follow-up. Two patients demonstrated evidence of local radiographic progression at last follow-up (7%). No toxicity could be directly attributed to SRS. In this SRS series, durable tumor control was achieved in 93% of patients with pilocytic astrocytoma, although continued follow up will be important giving the natural history of this disease. As demonstrated, SRS is an appropriate technique in the primary and recurrent treatment of pilocytic astrocytoma that offers favorable disease control and infrequent clinical toxicity.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA. .,Department of Radiation Oncology, University of Virginia Health System, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.
| | - M Sean Peach
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Ronald Kersh
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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25
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Gagliardi F, Bailo M, Spina A, Donofrio CA, Boari N, Franzin A, Fava A, Del Vecchio A, Bolognesi A, Mortini P. Gamma Knife Radiosurgery for Low-Grade Gliomas: Clinical Results at Long-Term Follow-Up of Tumor Control and Patients' Quality of Life. World Neurosurg 2017; 101:540-553. [PMID: 28216397 DOI: 10.1016/j.wneu.2017.02.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE First-line therapy for low-grade gliomas (LGGs) is surgery, in some cases followed by radiotherapy and chemotherapy. Gamma Knife radiosurgery (GKRS) has gained more relevance in the management of these tumors. The aim of this study was to assess efficacy and safety of GKRS for treatment of LGGs. METHODS Between 2001 and 2014, 42 treatments were performed on 39 patients harboring LGGs; 48% of patients underwent previous surgery, and 20.5% underwent previous radiotherapy. Mean tumor volume was 2.7 cm3, and median margin dose was 15 Gy. RESULTS Mean follow-up was 60.5 months (range, 6-164 months). Actuarial progression-free survival was 74.9%, 52.8%, and 39.1% at 1 year, 5 years, and 10 years; actuarial overall survival was 97.4%, 94.6%, and 91.8% at 9 months, 1 year, and 5 years. Solid tumor control was achieved in 69.2% of patients, whereas cystic enlargement was recorded in 12.9% of cases. At last follow-up, volume reduction was recorded in 57.7% of cases, and median volume decreased by 33.3%. Clinical improvement was observed in 52.4% of patients. Karnofsky performance scale score was improved in 15 patients (45.5%), unchanged in 17 patients (51.5%), and worsened in 1 patient (3%). Mean posttreatment scores of 36-item short form health survey domains did not significantly differ from scores in a healthy Italian population. CONCLUSIONS This study confirms safety and effectiveness of GKRS for LGGs in controlling tumor growth, relevantly improving patients' overall and progression-free survival. GKRS improved patients' functional performance and quality of life, optimizing social functioning and minimizing disease-related psychological impact.
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Affiliation(s)
- Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Michele Bailo
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Carmine A Donofrio
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Nicola Boari
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alberto Franzin
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Arianna Fava
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Service of Medical Physics, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Angelo Bolognesi
- Service of Radiation Oncology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Wang Z, Yan HM, Zhou XR, Liu JK, Chang JY, Wang YT. Spontaneous intratumoural and intraventricular haemorrhage associated with a pilomyxoid astrocytoma in the hypothalamic/chiasmatic region. J Clin Neurosci 2016; 33:217-220. [PMID: 27450285 DOI: 10.1016/j.jocn.2016.03.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/31/2016] [Accepted: 03/14/2016] [Indexed: 11/27/2022]
Abstract
Pilomyxoid astrocytoma (PMA) is a rare, low-grade glioma that is recognised as a variant of pilocytic astrocytoma. There have been few reports on this pathologic entity presenting with spontaneous haemorrhage. In this study, we report a rare case of PMA in the hypothalamic/chiasmatic region presenting with intratumoural and intraventricular haemorrhage. An external ventricular drain was urgently inserted. A ventriculo-peritoneal shunt (VP) was undergone 4weeks thereafter. The patient received fractionated Gamma Knife radiosurgery in another hospital 3weeks after the VP shunt. Three months later, subtotal resection of the tumour was performed in our hospital via a pterional approach. The pathological diagnosis was PMA. Postoperatively, no adjuvant therapy was given, and the neurologic deficits were improved. However, the presentation of endocrine deficits remained. Notably, PMAs in the hypothalamic/chiasmatic region presenting with massive intratumoural and intraventricular haemorrhage may result in a severe condition and long-term impairment of endocrine function. Long-term follow-up is required to monitor the recurrence of the tumour and endocrinopathy.
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Affiliation(s)
- Zhe Wang
- Department of Neurosurgery, Wei Fang People's Hospital, 151 Guangwen Street, Weifang 261041, China
| | - Hong-Mei Yan
- Department of Neurosurgery, Wei Fang People's Hospital, 151 Guangwen Street, Weifang 261041, China.
| | - Xiu-Rong Zhou
- Department of Neurosurgery, Wei Fang People's Hospital, 151 Guangwen Street, Weifang 261041, China
| | - Jin-Kai Liu
- Department of Neurosurgery, Wei Fang People's Hospital, 151 Guangwen Street, Weifang 261041, China
| | - Jian-Yong Chang
- Department of Neurosurgery, Wei Fang People's Hospital, 151 Guangwen Street, Weifang 261041, China
| | - Yu-Ting Wang
- Department of Neurosurgery, Wei Fang People's Hospital, 151 Guangwen Street, Weifang 261041, China
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27
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Murphy ES, Chao ST, Angelov L, Vogelbaum MA, Barnett G, Jung E, Recinos VR, Mohammadi A, Suh JH. Radiosurgery for Pediatric Brain Tumors. Pediatr Blood Cancer 2016; 63:398-405. [PMID: 26536284 DOI: 10.1002/pbc.25831] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/13/2015] [Indexed: 11/05/2022]
Abstract
The utility of radiosurgery for pediatric brain tumors is not well known. For children, radiosurgery may have an important role for treating unresectable tumors, residual disease, or tumors in the recurrent setting that have received prior radiotherapy. The available evidence demonstrates utility for some children with primary brain tumors resulting in good local control. Radiosurgery can be considered for limited residual disease or focal recurrences. However, the potential toxicities are unique and not insignificant. Therefore, prospective studies need to be performed to develop guidelines for indications and treatment for children and reduce toxicity in this population.
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Affiliation(s)
- Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene Barnett
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Jung
- Department of Radiation Oncology, John R. Marsh Cancer Center, Hagerstown, MD, USA
| | - Violette R Recinos
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza Mohammadi
- Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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28
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Tuleasca C, Negretti L, Magaddino V, Maeder P, Lhermitte B, Borruat FX, Levivier M. Biphasic response of a tecto-mesencephalic pilocytic astrocytoma after Gamma Knife surgery--A case report. Neurochirurgie 2015; 61:275-8. [PMID: 26072229 DOI: 10.1016/j.neuchi.2014.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/18/2014] [Accepted: 11/29/2014] [Indexed: 11/20/2022]
Abstract
Biphasic response (shrinkage-regrowth-shrinkage) of tumors has never previously been reported in the postoperative course, neither after microsurgery, nor after Gamma Knife surgery (GKS). We present the case of an adult with dorsal midbrain syndrome resulting from a pilocytic astrocytoma centered on the mesencephalic tectum. The tumor extended to the third ventricle and the thalamus. Initially, due to tumor growth, a biopsy was performed and histology established. Later, a ventriculocisternostomy for obstructive hydrocephalus was performed. Finally, GKS was performed, as the tumor continued to grow. After GKS, the lesion exhibited a biphasic response, with a major shrinkage at 3 months, regrowth within the target volume at 6 and 9 months and a second phase of important shrinkage at 12 months, which persisted for the next two years. The possible mechanisms for this particular response pattern are discussed.
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Affiliation(s)
- C Tuleasca
- Neurosurgery service, Gamma Knife center, CHU Vaudois, Lausanne, Switzerland; Medical image analysis laboratory (MIAL), CHU Vaudois, Lausanne, Switzerland; École politechnique fédérale de Lausanne, signal processing laboratory (LTS 5), Lausanne, Switzerland; Faculty of biology and medicine, university of Lausanne, Lausanne, Switzerland.
| | - L Negretti
- Radiation oncology service, CHU Vaudois, Lausanne, Switzerland; Radiation oncology department, Clinica Luganese, Lugano, Switzerland
| | - V Magaddino
- Institute of radiation physics, CHU Vaudois, Lausanne, Switzerland; Faculty of biology and medicine, university of Lausanne, Lausanne, Switzerland
| | - P Maeder
- Radiology department, CHU Vaudois, Lausanne, Switzerland; Faculty of biology and medicine, university of Lausanne, Lausanne, Switzerland
| | - B Lhermitte
- Neuropathology department, CHU Vaudois, Lausanne, Switzerland; Faculty of biology and medicine, university of Lausanne, Lausanne, Switzerland
| | - F-X Borruat
- Unité de neuro-ophtalmologie, service universitaire d'ophtalmologie, hôpital ophtalmique Jules-Gonin, Lausanne, Switzerland; Faculty of biology and medicine, university of Lausanne, Lausanne, Switzerland
| | - M Levivier
- Neurosurgery service, Gamma Knife center, CHU Vaudois, Lausanne, Switzerland; Faculty of biology and medicine, university of Lausanne, Lausanne, Switzerland
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Abstract
The use of radiotherapy in low-grade glioma has been a topic of controversy over the past 2 decades. Although earlier studies showed no overall survival benefit and no dose response, recent studies demonstrate a possible synergism between radiotherapy and chemotherapy. However, many questions remained unanswered regarding the proper management including the potential roles of biological imaging in treatment planning, the role of reirradiation after recurrence, the role of intensity-modulated radiation therapy and proton beam radiotherapy, and the proper choice of chemotherapy agents. Further clinical trials are necessary to help integrate these new therapies and technologies into clinical practice.
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30
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El-Shehaby AMN, Reda WAH, Abdel Karim KM, Emad Eldin RM, Esene IN. Gamma Knife radiosurgery for low-grade tectal gliomas. Acta Neurochir (Wien) 2015; 157:247-56. [PMID: 25510647 DOI: 10.1007/s00701-014-2299-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 12/01/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tectal gliomas are present in a critical location that makes their surgical treatment difficult. Stereotactic radiosurgery presents an attractive noninvasive treatment option. However, tectal gliomas are also commonly associated with aqueductal obstruction and consequently hydrocephalus. This necessitates some form of CSF diversion procedure before radiosurgery. The aim of the study was to assess the efficacy and safety of Gamma Knife radiosurgery for tectal gliomas. PATIENTS AND METHODS Between October 2002 and May 2011, 11 patients with tectal gliomas were treated with Gamma Knife radiosurgery. Five patients had pilocytic astrocytomas and six nonpilocytic astrocytomas. Ten patients presented with hydrocephalus and underwent a CSF diversion procedure [7 V-P shunt and 3 endoscopic third ventriculostomy (ETV)]. The tumor volume ranged between 1.2-14.7 cc (median 4.5 cc). The prescription dose was 11-14 Gy (median 12 Gy). RESULTS Patients were followed for a median of 40 months (13-114 months). Tumor control after radiosurgery was seen in all cases. In 6/11 cases, the tumors eventually disappeared after treatment. Peritumoral edema developed in 5/11 cases at an onset of 3-6 months after treatment. Transient tumor swelling was observed in four cases. Four patients developed cysts after treatment. One of these cases required aspiration and eventually disappeared, one became smaller spontaneously, and two remained stable. CONCLUSION Gamma Knife radiosurgery is an effective and safe technique for treatment of tectal gliomas. Tumor shrinkage or disappearance after Gamma Knife radiosurgery may preclude the need for a shunt later on.
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Kondziolka D, Shin SM, Brunswick A, Kim I, Silverman JS. The biology of radiosurgery and its clinical applications for brain tumors. Neuro Oncol 2014; 17:29-44. [PMID: 25267803 DOI: 10.1093/neuonc/nou284] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Stereotactic radiosurgery (SRS) was developed decades ago but only began to impact brain tumor care when it was coupled with high-resolution brain imaging techniques such as computed tomography and magnetic resonance imaging. The technique has played a key role in the management of virtually all forms of brain tumor. We reviewed the radiobiological principles of SRS on tissue and how they pertain to different brain tumor disorders. We reviewed the clinical outcomes on the most common indications. This review found that outcomes are well documented for safety and efficacy and show increasing long-term outcomes for benign tumors. Brain metastases SRS is common, and its clinical utility remains in evolution. The role of SRS in brain tumor care is established. Together with surgical resection, conventional radiotherapy, and medical therapies, patients have an expanding list of options for their care. Clinicians should be familiar with radiosurgical principles and expected outcomes that may pertain to different brain tumor scenarios.
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Affiliation(s)
- Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Samuel M Shin
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Andrew Brunswick
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Irene Kim
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Joshua S Silverman
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
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Chourmouzi D, Papadopoulou E, Konstantinidis M, Syrris V, Kouskouras K, Haritanti A, Karkavelas G, Drevelegas A. Manifestations of pilocytic astrocytoma: a pictorial review. Insights Imaging 2014; 5:387-402. [PMID: 24789122 PMCID: PMC4035491 DOI: 10.1007/s13244-014-0328-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Pilocytic astrocytoma can be challenging to diagnose. METHODS Its clinical presentations can differ, directly related to its size and location, and are relatively unreliable. Similarly, imaging findings also vary with the location of the pilocytic astrocytoma. RESULTS This review provides an overview of the different imaging findings regarding pilocytic astrocytomas using both conventional and advanced magnetic resonance imaging sequences according to tumour location; the findings are strongly related to the tumour's tendency to infiltrate surrounding structures, being able to carry out gross total resection, and finally the prognosis. CONCLUSIONS Knowledge of these imaging manifestations of pilocytic astrocytoma may be helpful to arrive at an accurate diagnosis. TEACHING POINTS • To recognise the various imaging findings of pilocytic astrocytoma on both conventional and advanced magnetic resonance imaging sequences. • To identify the characteristic imaging findings according to tumour location. • To discuss the relevant differential diagnoses of pilocytic astrocytoma in each tumour location.
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Affiliation(s)
- Danai Chourmouzi
- Department of Radiology, Interbalcan Medical Centre, Thessaloniki, Greece,
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33
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Monaco EA, Grandhi R, Niranjan A, Lunsford LD. The past, present and future of Gamma Knife radiosurgery for brain tumors: the Pittsburgh experience. Expert Rev Neurother 2014; 12:437-45. [DOI: 10.1586/ern.12.16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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35
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Weintraub D, Yen CP, Xu Z, Savage J, Williams B, Sheehan J. Gamma knife surgery of pediatric gliomas. J Neurosurg Pediatr 2012; 10:471-7. [PMID: 23061823 DOI: 10.3171/2012.9.peds12257] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT While some low-grade pediatric gliomas may be cured with resection, many patients harbor tumors that cannot be completely resected safely, are difficult to access via an open surgical approach, or recur. Gamma Knife surgery may be beneficial in the treatment of these tumors. METHODS The authors reviewed a consecutive series of 24 pediatric patients treated at the authors' institution between 1989 and 2011. All patients harbored tumors that were either surgically inaccessible or had evidence of residual or recurrent growth after resection. Progression-free survival was evaluated and correlated with clinical variables. Additional outcomes evaluated were clinical outcome, imaging response, and overall survival. RESULTS Between 1989 and 2011, 13 male and 11 female patients (median age 11 years, range 4-18 years) with gliomas were treated. Tumor pathology was pilocytic astrocytoma (WHO Grade I) in 15 patients (63%), WHO Grade II in 4 (17%), and WHO Grade III in 1 (4%). The tumor pathology was not confirmed in 4 patients (17%). The mean tumor volume at the time of treatment was 2.4 cm(3). Lesions were treated with a median maximum dose of 36 Gy, median of 3 isocenters, and median marginal dose of 15 Gy. The median duration of imaging follow-up was 74 months, and the median duration of clinical follow-up was 144 months. The tumors responded with a median decrease in volume of 71%. At last follow up, a decrease in tumor size of at least 50% was demonstrated in 18 patients (75%) and complete tumor resolution was achieved in 5 (21%). Progression-free survival at last follow-up was achieved in 20 patients (83%). Progression was documented in 4 patients (17%), with 3 patients requiring repeat resection and 1 patient dying. The initial tumor volume was significantly greater in patients with disease progression (mean volume 4.25 vs 2.0 cm(3), p < 0.001). Age, tumor pathology, tumor location, previous radiation, Karnofsky Performance Scale score, symptom duration, and target dosage did not differ significantly between the 2 groups. CONCLUSIONS Gamma Knife surgery can provide good clinical control of residual or recurrent gliomas in pediatric patients. Worse outcomes in the present series were associated with larger tumor volumes at the time of treatment.
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Affiliation(s)
- David Weintraub
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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Bernier-Chastagner V, Supiot S, Carrie C, Helfre S. [Stereotactic radiotherapy in pediatric indications]. Cancer Radiother 2012; 16 Suppl:S111-5. [PMID: 22658965 DOI: 10.1016/j.canrad.2011.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 08/11/2011] [Accepted: 09/01/2011] [Indexed: 11/26/2022]
Abstract
Stereotactic radiotherapy is a very high precision procedure, which has been limited to radiosurgery for a long time. Technological improvements allowed the development of radiotherapy in stereotactic conditions, leading to a lot of innovations. Previously indicated for cerebral pathologies, this procedure is now developed for extracerebral locations. In paediatrics, stereotactic radiotherapy is still limited, delivered precociously, due to the possibility of long-term late effects that needs to be addressed. This review reports the different useful conditions, technical evolutions, and the current validated paediatric indications, with differences from adults, and future directions.
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Affiliation(s)
- V Bernier-Chastagner
- Département de radiothérapie, centre Alexis-Vautrin, avenue de Bourgogne, Vandœuvre-lès-Nancy cedex, France.
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Lizarraga KJ, Gorgulho A, Lee SP, Rauscher G, Selch MT, DeSalles AAF. Stereotactic radiation therapy for progressive residual pilocytic astrocytomas. J Neurooncol 2012; 109:129-35. [PMID: 22644536 DOI: 10.1007/s11060-012-0877-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 04/05/2012] [Indexed: 11/30/2022]
Abstract
This report shows the results of stereotactic radiation therapy for progressive residual pilocytic astrocytomas. Medical records of patients who had undergone stereotactic radiation therapy for a progressive residual pilocytic astrocytoma were reviewed. Between 1995 and 2010, 12 patients with progression of a residual pilocytic astrocytoma underwent stereotactic radiation therapy at UCLA. Presentation was headache (4), visual defects (3), hormonal disturbances (2), gelastic seizures (2) and ataxia (1). MRI showed a cystic (9), mixed solid/cystic (2) or solid tumor (1); located in the hypothalamus (5), midbrain (3), thalamus (2), optic chiasm (1) or deep cerebellum (1). Median age was 21 years (range 5-41). Nine tumors received stereotactic radiotherapy (SRT). Three tumors received stereotactic radiosurgery (SRS), two of them to their choline positive regions. SRT median total dose was 50.4 Gy (40-50.4 Gy) in a median of 28 fractions (20-28), using a median fraction dose of 1.8 Gy (1.8-2 Gy) to a median target volume of 6.5 cm(3). (2.4-33.57 cm(3)) SRS median dose was 18.75 Gy (16.66-20 Gy) to a median target volume of 1.69 cm(3) (0.74-2.22 cm(3)). Median follow-up time was 37.5 months. Actuarial long-term progression-free and disease-specific survival probabilities were 73.3 and 91.7 %, respectively. No radiation-induced complications were observed. Stereotactic radiation therapy is a safe and effective modality to control progressive residual pilocytic astrocytomas. Better outcomes are obtained with SRT to entire tumor volumes than with SRS targeting choline positive tumor regions.
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Affiliation(s)
- Karlo J Lizarraga
- Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles (UCLA), 10945 Le Conte Avenue, Room 2120, Los Angeles, CA, 90095, USA
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Static jaw collimation settings to minimize radiation dose to normal brain tissue during stereotactic radiosurgery. Med Dosim 2012; 37:391-5. [PMID: 22552119 DOI: 10.1016/j.meddos.2012.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 02/16/2012] [Accepted: 02/22/2012] [Indexed: 11/22/2022]
Abstract
At the University of Arkansas for Medical Sciences (UAMS) intracranial stereotactic radiosurgery (SRS) is performed by using a linear accelerator with an add-on micromultileaf collimator (mMLC). In our clinical setting, static jaws are automatically adapted to the furthest edge of the mMLC-defined segments with 2-mm (X jaw) and 5-mm (Y jaw) margin and the same jaw values are applied for all beam angles in the treatment planning system. This additional field gap between the static jaws and the mMLC allows additional radiation dose to normal brain tissue. Because a radiosurgery procedure consists of a single high dose to the planning target volume (PTV), reduction of unnecessary dose to normal brain tissue near the PTV is important, particularly for pediatric patients whose brains are still developing or when a critical organ, such as the optic chiasm, is near the PTV. The purpose of this study was to minimize dose to normal brain tissue by allowing minimal static jaw margin around the mMLC-defined fields and different static jaw values for each beam angle or arc. Dose output factors were measured with various static jaw margins and the results were compared with calculated doses in the treatment planning system. Ten patient plans were randomly selected and recalculated with zero static jaw margins without changing other parameters. Changes of PTV coverage, mean dose to predefined normal brain tissue volume adjacent to PTV, and monitor units were compared. It was found that the dose output percentage difference varied from 4.9-1.3% for the maximum static jaw opening vs. static jaw with zero margins. The mean dose to normal brain tissue at risk adjacent to the PTV was reduced by an average of 1.9%, with negligible PTV coverage loss. This dose reduction strategy may be meaningful in terms of late effects of radiation, particularly in pediatric patients. This study generated clinical knowledge and tools to consistently minimize dose to normal brain tissue.
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Abstract
PURPOSE OF REVIEW This review provides information and an update on stereotactic radiosurgery (SRS) equipment, with a focus on intracranial lesions and brain neoplasms. RECENT FINDINGS Gamma Knife radiosurgery represents the gold standard for intracranial radiosurgery, using a dedicated equipment, and has recently evolved with a newly designed technology, Leksell Gamma Knife Perfexion. Linear accelerator-based radiosurgery is more recent, and originally based on existing systems, either adapted or dedicated to radiosurgery. Equipment incorporating specific technologies, such as the robotic CyberKnife system, has been developed. Novel concepts in radiation therapy delivery techniques, such as intensity-modulated radiotherapy, were also developed; their integration with computed tomography imaging and helical delivery has led to the TomoTherapy system. Recent data on the management of intracranial tumors with radiosurgery illustrate the trend toward a larger use and acceptance of this therapeutic modality. SUMMARY SRS has become an important alternative treatment for a variety of lesions. Each radiosurgery system has its advantages and limitations. The 'perfect' and ubiquitous system does not exist. The choice of a radiosurgery system may vary with the strategy and needs of specific radiosurgery programs. No center can afford to acquire every technology, and strategic choices have to be made. Institutions with large neurosurgery and radiation oncology programs usually have more than one system, allowing optimization of the management of patients with a choice of open neurosurgery, radiosurgery, and radiotherapy. Given its minimally invasive nature and increasing clinical acceptance, SRS will continue to progress and offer new advances as a therapeutic tool in neurosurgery and radiotherapy.
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Hallemeier CL, Pollock BE, Schomberg PJ, Link MJ, Brown PD, Stafford SL. Stereotactic radiosurgery for recurrent or unresectable pilocytic astrocytoma. Int J Radiat Oncol Biol Phys 2011; 83:107-12. [PMID: 22019245 DOI: 10.1016/j.ijrobp.2011.05.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/28/2011] [Accepted: 05/08/2011] [Indexed: 12/31/2022]
Abstract
PURPOSE To report the outcomes in patients with recurrent or unresectable pilocytic astrocytoma (PA) treated with Gamma Knife stereotactic radiosurgery (SRS). METHODS AND MATERIALS Retrospective review of 18 patients (20 lesions) with biopsy-confirmed PA having SRS at our institution from 1992 through 2005. RESULTS The median patient age at SRS was 23 years (range, 4-56). Thirteen patients (72%) had undergone one or more previous surgical resections, and 10 (56%) had previously received external-beam radiation therapy (EBRT). The median SRS treatment volume was 9.1 cm(3) (range, 0.7-26.7). The median tumor margin dose was 15 Gy (range, 12-20). The median follow-up was 8.0 years (range, 0.5-15). Overall survival at 1, 5, and 10 years after SRS was 94%, 71%, and 71%, respectively. Tumor progression (local solid progression, n = 4; local solid progression + distant, n = 1; distant, n = 2; cyst development/progression, n = 4) was noted in 11 patients (61%). Progression-free survival at 1, 5, and 10 years was 65%, 41%, and 17%, respectively. Prior EBRT was associated with inferior overall survival (5-year risk, 100% vs. 50%, p = 0.03) and progression-free survival (5-year risk, 71% vs. 20%, p = 0.008). Nine of 11 patients with tumor-related symptoms improved after SRS. Symptomatic edema after SRS occurred in 8 patients (44%), which resolved with short-term corticosteroid therapy in the majority of those without early disease progression. CONCLUSIONS SRS has low permanent radiation-related morbidity and durable local tumor control, making it a meaningful treatment option for patients with recurrent or unresectable PA in whom surgery and/or EBRT has failed.
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Nath SK, Carmona R, Rose BS, Simpson DR, Russell M, Lawson JD, Mundt AJ, Murphy KT. Observed magnetic resonance imaging changes in pediatric patients treated with stereotactic radiosurgery for intracranial tumors. Childs Nerv Syst 2011; 27:399-406. [PMID: 20927529 PMCID: PMC3042094 DOI: 10.1007/s00381-010-1288-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Accepted: 07/30/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE This study seeks to characterize magnetic resonance imaging (MRI) changes following stereotactic radiosurgery (SRS) of pediatric brain malignancies. METHODS Serial MRI evaluations were performed on 21 lesions treated with SRS for either medulloblastoma (n=12), juvenile pilocytic astrocytoma (n=4), ependymoma (n=2), atypical rhabdoid teratoid tumor (n=2), or pineocytoma (n=1). Prescription doses ranged from 14 to 30 Gy in one to five fractions. Tumor response was qualified as complete (CR), partial (PR), stable disease (SD), or progressive disease (PD) according to the RECIST v1.1. Median radiographic follow-up after SRS was 17 months. RESULTS A total of 80 follow-up MRI scans were reviewed with a median of eight per patient. During serial MRI evaluation, eight lesions met criteria for PD at a median of 6 months. However, of these, three (37%) represented transient tumor edema with two lesions later developing a CR at a median of 15 months and one persisting as SD at 12 months. The remaining five lesions were true local failures. Of the 13 lesions that did not show evidence of PD, a CR was obtained in 11 lesions at a median of 3 months (range, 2-6), and SD was seen in the remaining two tumors at last follow-up. CONCLUSION Lesion enlargement following SRS for pediatric intracranial tumors is common, and a proportion of patients meeting requirements for PD at early radiographic follow-up may later develop complete resolution of their lesions. Physicians should be aware of these radiographic changes to avoid unwarranted medical and surgical interventions.
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Affiliation(s)
- Sameer K Nath
- Department of Radiation Oncology and Center for Advanced Radiotherapy Technologies, Rebecca and John Moores Cancer Comprehensive Cancer Center, University of California San Diego, La Jolla, CA 92093-0843, USA.
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Park KJ, Kano H, Kondziolka D, Niranjan A, Flickinger JC, Lunsford LD. Gamma Knife surgery for subependymal giant cell astrocytomas. Clinical article. J Neurosurg 2010; 114:808-13. [PMID: 20950089 DOI: 10.3171/2010.9.jns10816] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors report their experience of using Gamma Knife surgery (GKS) in patients with subependymal giant cell astrocytoma (SEGA). METHODS Over a 20-year period, the authors identified 6 patients with SEGAs who were eligible for GKS. The median patient age was 16.5 years (range 7-55 years). In 4 patients, GKS was used as a primary management therapy. One patient underwent radiosurgery for recurrent tumors after prior resection, and in 1 patient GKS was used as an adjunct after subtotal resection. The median tumor volume at GKS was 2.75 cm(3) (range 0.7-5.9 cm(3)). A median radiation dose of 14 Gy (range 11-20 Gy) was delivered to the tumor margin. RESULTS The median follow-up duration was 73 months (range 42-90 months). Overall local tumor control was achieved in 4 tumors (67%) with progression-free periods of 24, 42, 57, and 66 months. Three tumors regressed and one remained unchanged. In 2 patients the tumors progressed, and in 1 of these patients the lesion was managed by repeated GKS with subsequent tumor regression. The other relatively large tumor (5.9 cm(3)) was excised 9 months after GKS. The progression-free period for all GKS-managed tumors varied from 9 to 66 months. There were no cases of hydrocephalus or GKS-related morbidity. CONCLUSIONS Gamma Knife surgery may be an additional minimally invasive management option for SEGA in a patient who harbors a small but progressively enlarging tumor when complete resection is not safely achievable. It may also benefit patients with a residual or recurrent tumor that has progressed after surgery.
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Affiliation(s)
- Kyung-Jae Park
- Department of Neurological Surgery, University of Pittsburgh, Center for Image-Guided Neurosurgery, Pittsburgh, Pennsylvania, USA
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