Stereotactic radiation treatment for recurrent nonbenign meningiomas

OBJECT: The authors analyzed the results of stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) for the treatment of recurrent meningiomas that were described at initial resection as showing aggressive, atypical, or malignant features (nonbenign). METHODS: Twenty-five patients who underwent SRS and/or SRT for nonbenign meningiomas between December 1992 and August 2004 were included. Thirteen of these patients underwent treatment for multiple primary or recurrent lesions. In all, 52 tumors were treated. All histological sections were reviewed and reclassified according to World Health Organization (WHO) 2000 guidelines as benign (Grade I), atypical (Grade II), or anaplastic (Grade III) meningiomas. The median follow-up period was 42 months. Seventeen (68%) of the cases were reclassified as follows: WHO Grade I (five cases), Grade II (11 cases), and Grade III (one case). Malignant progression occurred in eight cases (32%) during the follow-up period; these cases were considered as a separate group. The 3-year progression-free survival (PFS) rates for the Grades I, II, and III, and malignant progression groups were 100, 83, 0, and 11%, respectively (p < 0.001). In the Grade II group, the 3-year PFS rates for patients treated with SRS and SRT were 100 and 33%, respectively (p = 0.1). After initial treatment, 22 new tumors required treatment using SRS or SRT; 17 (77%) of them occurred inside the original resection cavity. Symptomatic edema developed in one patient (4%). CONCLUSIONS: Stereotactic radiation treatment provided effective local control of "aggressive" Grade I and Grade II meningiomas, whereas Grade III lesions were associated with poor outcome. The outcome of cases in the malignant progression group was intermediate between that of the Grade II and Grade III groups, with the lesions showing a tendency toward malignancy.     

Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas

OBJECT: To evaluate long-term outcomes of patients who have undergone stereotactic radiosurgery for cavernous sinus meningiomas, the authors retrospectively reviewed their 14-year experience with these cases. METHODS: One hundred seventy-six patients harbored meningiomas centered within the cavernous sinus. Seventeen patients were lost to follow-up review, leaving 159 analyzable patients, in whom 164 procedures were performed. Seventy-six patients (48%) underwent adjuvant radiosurgery after one or more attempts at surgical resection. Eighty-three patients (52%) underwent primary radiosurgery. Two patients (1%) had previously received fractionated external-beam radiation therapy. Four patients (2%) harbored histologically verified atypical or malignant meningiomas. Conformal multiple isocenter gamma knife surgery was performed. The median dose applied to the tumor margin was 13 Gy. Neurological status improved in 46 patients (29%), remained stable in 99 (62%), and eventually worsened in 14 (9%). Adverse effects of radiation occurred after 11 procedures (6.7%). Tumor volumes decreased in 54 patients (34%), remained stable in 96 (60%), and increased in nine (6%). The actuarial tumor control rate for patients with typical meningiomas was 93.1 +/- 3.3% at both 5 and 10 years. For the 83 patients who underwent radiosurgery as their sole treatment, the actuarial tumor control rate at 5 years was 96.9 +/- 3%. CONCLUSIONS: Stereotactic radiosurgery provided safe and effective management of cavernous sinus meningiomas. We believe it is the preferred management strategy for tumors of suitable volume (average tumor diameter < or = 3 cm or volume < or = 15 cm3).     

Stereotactic radiosurgery without radiation therapy providing high local tumor control of multiple brain metastases from renal cell carcinoma.

The aim of this study was to analyse treatment effects after stereotactic radiosurgery (SRS) without whole brain radiation therapy (WBRT) as primary treatment for patients harboring brain metastases of renal cell carcinoma (RCC). During an 8-year period, 85 patients with 376 brain metastases from RCC underwent 134 outpatient SRS procedures. 65 % of all patients had multiple brain metastases. The median tumor volume was 1.2 cm (3) (range: 0.1 - 14.2 cm (3)). Mean prescribed tumor dose was 21.2 (+/- 3.2) Gy. Local/distant tumor recurrences were treated by additional SRS in cases of stable systemic disease. Overall median survival was 11.1 months after SRS. The local tumor control rate after SRS was 94 %. Most patients (78 %) died because of systemically progressing cancer. A KPS > 70 and RTOG class I were related to prolonged survival time. Patients of the RTOG groups I, II and III survived for 24.2 months, 9.2 months and 7.5 months, respectively. There was no permanent morbidity after SRS. 11 patients (12.9 %) showed transient radiogenic complications and 3 patients (3.5 %) died because of intratumoral bleedings after SRS. Stereotactic radiosurgery alone achieves excellent local tumor control rates for patients with small brain metastases from renal cell carcinoma.     

Stereotactic radiosurgery for pituitary metastases

Background

We evaluated the role of Gamma Knife SRS in the multidisciplinary management of metastatic cancer to the pituitary gland.

Methods

We retrospectively reviewed records of 18 consecutive pituitary metastasis patients who underwent Gamma Knife SRS during a 21-year experience. The median patient age was 57.6 years (range, 27.0-81.1 years). There were 5 patients who had initial surgical resection of their pituitary metastasis, 5 who had fractionated radiation, and 7 who had CT before SRS. The median radiosurgery target volume was 3.5 mL (range, 0.2-18.0 mL), and the median marginal dose was 13.0 Gy (range, 9-18 Gy).

Results

The overall survival after SRS at 3, 6, and 12 months, respectively, was 66%, 36%, and 18%. The median survival after SRS was 5.2 months. The progression-free survival after SRS was 100% and 66.7% at 6 and 12 months, respectively. The only factor associated with an improved overall survival was younger age at presentation. Diabetes insipidus improved in 3 (42.9%) of 7 patients. Neurological symptoms or signs improved in 4 (50.0%) of 8 patients. Three (16.7%) patients developed new neurological deficits due to tumor progression despite SRS.

Conclusion

Development of a pituitary metastasis is an ominous finding in the context of systemic cancer. Stereotactic radiosurgery is an effective palliative approach for most patients with pituitary metastasis.     

Gamma-knife-based stereotactic radiosurgery for uveal melanoma

Nineteen patients with uveal melanoma were treated with Gamma-Knife-based stereotactic radiosurgery (SRS). The radiation dose was 40 Gy prescribed to the 50% isodose line for all patients. The median follow-up was 40 months. The 3- and 5-year overall survival rates were 86 and 55%, respectively. The 3- and 5-year tumor control rates were both 94%. Six of the 19 treated patients (32%) developed distant metastasis 31-75 months after SRS. Out of the 19 patients treated with SRS, 2 had improved, 4 had stable and 13 had worse vision in the treated eye. Gamma-Knife-based SRS appears to provide excellent local control of uveal melanoma. The risk of distant metastasis is significant. Effective systemic therapy is to be explored to improve the treatment outcome of uveal melanoma.     

Adjuvant stereotactic radiosurgery for anaplastic ependymoma

OBJECT: The purpose of this retrospective study is to evaluate the role of stereotactic radiosurgery using the Gamma Knife as an adjuvant to other modalities used in the treatment of malignant ependymomas of both children and adults and to assess its efficacy in terms of tumor control and overall survival. METHOD: Between 1987 and 1998, 22 patients in the age range of 1.5-65 years (mean age 22. 3) with progressive anaplastic ependymoma were treated by stereotactic radiosurgery using the 201 source Co-60 Leksell Gamma Knife at the University of Pittsburgh. The irradiated tumor volume varied from 0.84 to 36.8 cm(3) (mean 13.7). The median dose delivered to the tumor margin was 16.1 Gy (range 10-20), and the mean maximal dose was 32.2 Gy (range 20-40). The disease-free survival, the tumor control rate and the overall survival were recorded to evaluate the efficacy of radiosurgery. The median follow-up from radiosurgery was 21 months (range 4-84). RESULTS: Median survival after radiosurgery was 2.2 years (46.6 +/- 12.1% 5-year actuarial). Median survival from the initial diagnosis was 10. 1 years (50.3 +/- 12.5% at 5 years, 37.7 +/- 14.4% at 10 years). Reduction or stabilization of the treated tumor was seen in 16 out of 22 (68%) patients. Forty-one percent of the patients eventually developed delayed distant cerebral recurrence outside the treated volume. The 5-year actuarial rates for local control and cranial control at any location were 62.3 +/- 13.6% and 32.4 +/- 10.8%, respectively. No complication occurred as a side effect of radiosurgery. CONCLUSION: For patients with locally recurrent or progressive anaplastic ependymomas, Gamma Knife stereotactic radiosurgery proved to be safe and effective as a salvage adjuvant therapy to achieve local tumor control and improve survival.     

Recurrent Malignant Gliomas Treated with Radiosurgery

The inability to control malignant glioma results in a high incidence of local failure and poor survival. Focal therapy such as radiosurgery permits delivery of a high dose of radiation with moderate toxicity. This report summarizes the outcome of patients with recurrent malignant glioma treated with radiosurgery at University of Wisconsin Hospital, between January 1989 and December 1997, when 30 patients were treated radiosurgically. All patients had undergone and failed external beam radiotherapy (median dose of 59.4 Gy) prior to radiosurgery. All recurrences were detected by clinical deterioration and confirmed by radiographic progression. No patient was treated for radiographic progression only in the context of a screening protocol. Eight out of 30 patients underwent subtotal resection prior to radiosurgery and 3 received chemotherapy along with radiosurgery. Radiosurgery was delivered in a single fraction using a modified linear accelerator. The median tumor volume was 7.2 cm³ (range 0.42–35.1 cm³) and the median minimal tumor dose was 12 Gy at the 50–80% isodose line. Median follow-up is 70 months. The median overall survival is 8 months; the 1- and 2-year survival rates are 20% and 9%, respectively. For patients with an initial diagnosis of non-glioblastoma, the median survival is 11 months and for those with glioblastoma the median survival is 7 months. The median progression-free survival is 4 months for the entire cohort, 5 months for nonglioblastoma, and 3 months for glioblastoma. The 1-year actuarial reoperation rate after radio-surgery is 7.6%. Radiosurgery for recurrent malignant glioma may improve short-term survival for selected patients with a lower reoperation rate than brachytherapy.     

Surgical resection and permanent brachytherapy for recurrent atypical and malignant meningioma

OBJECTIVE: Recurrent atypical and malignant meningiomas are difficult to treat successfully. Chemotherapy to date has been unsuccessful, and radiosurgery is limited to smaller tumors. Reoperation alone provides limited tumor control and limited prolonged survival. The addition of brachytherapy at the time of operation is an option. Here, we report the results of our series of patients with recurrent malignant meningioma treated with resection and brachytherapy with permanent low-dose (125)I. METHODS: The charts of patients in our database with recurrent atypical and malignant meningiomas treated by surgical resection and permanent (125)I brachytherapy at the University of California, San Francisco, between 1988 and 2002 were selected for this study. Calculations of disease-free survival and overall survival curves were made by the Kaplan-Meier actuarial method. Univariate analysis between Kaplan-Meier curves was based on the log-rank statistic, with a significance level set at a value of P 相似文献   

Long-term outcomes of Gamma Knife surgery for cavernous sinus meningioma

OBJECT: The aim of this study was to evaluate long-term outcomes, including tumor control and neurological function, in patients with cavernous sinus meningiomas treated using Gamma Knife surgery (GKS). METHODS: One hundred fifteen patients with cavernous sinus meningiomas, excluding atypical or malignant meningiomas, were treated with GKS between 1991 and 2003. Forty-nine patients (43%) underwent GKS as the initial treatment. The mean tumor volume was 14 cm3, and the mean maximum and margin doses applied to the tumor were 27 and 13 Gy, respectively. The median follow-up period was 62 months. During the follow-up, 111 patients were able to be evaluated with neuroimaging. RESULTS: The actuarial 5- and 10-year progression-free survival rates were 87 and 73%, respectively. Similarly, the actuarial 5- and 10-year focal tumor control rates were 94 and 92%, respectively. Regarding functional outcomes, 43 patients (46%) experienced some degree of improvement, 40 (43%) remained stable, and 11 (12%) had worse preexisting or newly developed symptoms. Patients who underwent GKS as the initial treatment experienced significant improvement of their symptoms (p = 0.006). CONCLUSIONS: Gamma Knife surgery is a safe and effective treatment over the long term in selected patients with cavernous sinus meningiomas. Tumor progression is more likely to occur from the lesion margin outside the treatment volume. In small to medium-sized tumors, GKS is an excellent alternative to resection, preserving good neurological function. For relatively large-sized tumors, low-dose radiosurgery (< or = 12 Gy) is acceptable for the prevention of tumor progression.     

Radiosurgery as primary management for meningiomas extending into the internal auditory canal

Stereotactic radiosurgery is increasingly utilized as primary management for patients with skull base meningiomas. This study reviews the results of stereotactic radiosurgery for patients with meningiomas extending into the internal auditory canal (IAC) to determine the risk of facial weakness or hearing loss. From 1990 to 2002, 16 patients had radiosurgery for meningiomas extending into the IAC. The median patient age was 63 years. Ten patients had symptoms of vestibulocochlear nerve dysfunction before radiosurgery. The median tumor volume was 5.1 cm3; the median tumor extension into the IAC was 7 mm (range, 3-12). The median tumor margin dose was 15 Gy. The median follow-up was 36 months. Ten meningiomas (63%) decreased in size, and 6 tumors were unchanged. No patient developed facial weakness. One patient (6%) had worsened facial sensation. Three of 14 patients (21%) with either normal hearing clinically (n = 5) or documented Gardner-Robertson class 1-2 before radiosurgery (n = 9) had decreased hearing after radiosurgery. The 1-, 2- and 5-year actuarial incidences of hearing preservation were 93, 84 and 42%, respectively. Three patients (19%) had improved hearing after radiosurgery. One patient with class 2 hearing improved to class 1; 2 patients with no speech discrimination before radiosurgery (class 5) improved to a class 3 status following the procedure. The risk of facial weakness or hearing loss is low after radiosurgery for patients with meningiomas extending into the IAC. Radiosurgery is an excellent alternative to surgical excision for meningiomas in this location, especially if a subtotal resection is likely or a hearing-sacrificing operation such as a translabyrinthine approach is contemplated.     

The management of second primary lung cancers. A single centre experience in 15 years.

OBJECTIVE: In patients treated for an initial lung cancer, the cumulative risk of developing a second primary lung cancer is a recognised occurrence. This study reviews our experience in the clinical assessment and surgical management of second primary lung cancer (SPLC). METHODS: Between 1985-1999 a series of 892 patients with primary carcinoma of lung underwent surgical resection with curative intent in our institution. Using criteria set out by Martini and Melamed (J Thorac Cardiovasc Surg 70 (1975) 606) we were able to identify 51 patients who had developed a SPLC identified as the first site of re-occurrence. RESULTS: Forty-one patients developed a metachronous SPLC within a mean of 46+/-14 months of the first operation while ten patients had synchronous double lung cancer (six unilateral, four bilateral). The cumulative probability of cancer free interval for metachronous cancers was 39% at 3 years, 15% at 5 years and 2% at 10 years. There were three postoperative deaths among the metachronous cancers (7.5%) and there were no operative deaths among patients with synchronous cancers. The overall actuarial 5-year survival for all patients with SPLC was 38% with a median survival of 40 months (range 1-142 months). The actuarial 5-year survival for metachronous SPLC was 44%, median survival of 49 months (range 1-142 months), while the actuarial 5-years survival for synchronous SLPC was 10% with a median survival of 31 months (range 4-78 months). CONCLUSION: Aggressive assessment and surgical intervention is safe, effective and warranted in patients with a second lung primary cancer if they satisfy the usual criteria of operability after full assessment. This is true for patients with metachronous cancers, while patients with synchronous cancers tend to have worse prognosis. A long term follow-up policy after the initial resection of the primary lung cancer is recommended at intervals of 6 months for at least 3-5 years and then annually to enable the early detection of the second cancer.     

The use of stereotactic radiosurgery in the management of meningiomas

This is a systematic review of a consecutive series of 309 meningiomas treated with gamma knife stereotactic radiosurgery between 1994 and 2000. There was an extreme selection bias towards lesions unfavourable for surgery, determined by the patients referred for treatment: 70% of tumours involved the skull base, 47% specifically the cavernous sinus: 15% of patients had multiple meningiomatosis or type 2 neurofibromatosis. Tumour histology was the main determinant of growth control (p < 0.001), the 5-year actuarial control rates being 87% for typical meningiomas, 49% for atypical tumours and 0% for malignant lesions. Complications from radiosurgery were rare, occurring in 3% of tumours, and were most frequently trigeminal and eye movement disturbances treating cavernous sinus meningiomas. Given the problems inherent in managing these tumours, radiosurgery is a valuable strategy and adjuvant treatment for these meningiomas.     

Stereotactic radiosurgery for patients with "radioresistant" brain metastases

OBJECTIVE: Our aim was to evaluate the efficacy of stereotactic radiosurgery (SRS) for the treatment of patients with brain metastases that have been determined to be "radioresistant" on the basis of histological examination. METHODS: We reviewed the medical records of 41 consecutive patients who presented with 83 brain metastases from radioresistant primaries and subsequently underwent SRS. All patients were followed until death or for a median of 31 months after SRS. Tumor histologies included renal cell carcinoma (16 patients), melanoma (23 patients), and sarcoma (2 patients). Eighteen patients (44%) had a solitary metastasis, and 23 patients (56%) had multiple metastases. RESULTS: The median overall survival time was 14.2 months after SRS. On the basis of univariate analysis, systemic disease status (P = 0.006) and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (P = 0.005) were associated with survival. The median survival time was 23.5 months for patients in RPA Class I status and 10.5 months for patients in RPA Class II or III status. There was a trend (P = 0.12) toward improved median survival for patients with renal cell carcinoma (17.8 mo) as compared with patients with melanoma (9.7 mo). Multivariate analysis showed RPA class (P = 0.038) and histological diagnosis of primary tumor (P < 0.001) to be independent predictors for overall survival. In the 35 patients who underwent follow-up imaging, 9 (12%) of 73 tumors recurred locally. In 54% of the patients, distant brain failure (DBF) developed. Whole brain radiotherapy (WBRT) improved local control and decreased DBF, according to the univariate and multivariate analyses. Patients who received adjuvant WBRT in addition to SRS had 6-month actuarial local control of 100% as compared with 85% among those who did not receive WBRT (P = 0.018). Patients who received adjuvant WBRT with SRS had a 6-month actuarial DBF rate of 17%, as compared with a rate of 64% among patients who had SRS alone (P = 0.0027). CONCLUSION: Well-selected patients with brain metastases from radioresistant primary tumors who undergo SRS survive longer than historical controls. RPA Class I status and primary renal cell carcinoma predict longer survival. Adjuvant WBRT improves local control and decreases DBF but does not affect overall survival. Further studies are needed to determine which patients should receive WBRT.     

Optimal dose of stereotactic radiosurgery for acoustic neuromas: A systematic review

Radiosurgery is increasingly employed in the treatment of acoustic neuroma, but the optimal dose in terms of long-term tumour control and minimal adverse effects has not been established. We performed a systematic review of the published literature of radiosurgery of acoustic neuroma to assess whether the use of low dose radiosurgery is as effective as high dose treatment. Reports of radiosurgery for acoustic neuroma were identified through a Medline search. Studies with at least 15 patients and a median follow-up longer than 12 months were included. The relationship between actuarial 5-year progression-free survival (PFS), and tumour and treatment parameters was examined. Forty-two studies were included. Tumour control following lower radiosurgery doses was similar to that reported following high doses. Only 12 studies reported actuarial outcomes at 5 years. There was no relationship between PFS at 5 years and dose to the tumour margin. Radiosurgery of larger tumours was associated with lower 5 year PFS (p < 0.05). Although on initial inspection radiosurgery of acoustic neuroma with doses of 12 - 13 Gy seems to be as effective as higher dose treatment, the available reports are subject to a number of confounding factors, are not sufficiently statistically powered and there is only limited long-term actuarial outcome data. Currently, available studies do not provide sufficient confidence to support the claim that low dose radiosurgery is equally effective as higher doses in the long-term control of acoustic neuroma.     

Radiosurgery for chordomas and chondrosarcomas of the skull base

OBJECT: Chordomas and chondrosarcomas of the skull base are aggressive and locally destructive tumors with a high tendency for local progression despite treatment. The authors evaluated the effect of stereotactic radiosurgery (SRS) on local tumor control and survival. METHODS: Twenty-eight patients with histologically confirmed chordomas (18) or chondrosarcomas (10) underwent Gamma Knife SRS either as primary or adjuvant treatment. Their ages ranged from 17 to 72 years (median 44 years). The most common presenting symptom was diplopia (26 patients, 93%). In two patients, SRS was the sole treatment. Twenty-six patients underwent between one and five additional surgical procedures. Two underwent an initial transsphenoidal biopsy. The average tumor volume was 9.8 cm3. The median dose to the tumor margin was 16 Gy. RESULTS: No patient was lost to follow-up. Transient symptomatic adverse radiation effects developed in only one patient. The actuarial local tumor control for chondrosarcomas at 5 years was 80 +/- 10.1%. For chordomas both the actuarial tumor control and survival was 62.9 +/- 10.4%. CONCLUSIONS: Stereotactic radiosurgery is an important option for skull base chordomas and chondrosarcomas either as primary or adjunctive treatment. Multimodal management appears crucial to improve tumor control in most patients.     

Stereotactic radiosurgery plus intracavitary irradiation in the salvage of nasopharyngeal carcinoma

BACKGROUND: We sought to assess the efficacy and complications of linear accelerator-based stereotactic radiosurgery (SRS) plus intracavitary irradiation (ICI) as salvage treatment for local persistent and recurrent nasopharyngeal carcinoma (NPC) after primary external beam radiotherapy (EBRT). METHODS: Between July 1995 and June 2003, 36 patients (25 men and 11 women; median age, 48 years; range, 22-66 years) with local recurrent NPC confined to the nasopharynx (rT1) or limited extension to the parapharynx and nasal cavity (rT2) were treated with SRS plus ICI. Nineteen patients had rT1 and 17 had rT2 disease. Five patients (13.8%) had persistent disease, and 31 patients (86.1%) had recurrent disease using the definition of >4 months after the primary treatment as recurrent relapse. The median target volume was 36.3 cm(3) (range, 10.3-56.2 cm(3)) for the SRS treatment. All patients received 18 Gy to the 90% isodose line followed by two separate ICI 6 Gy each to 0.5 cm from the surface of the endotracheal balloon. Patients were assessed with serial nasoendoscopy and repeat scans (CT or MRI) at 3 months, and suspicious lesions were rebiopsied. RESULTS: The median follow-up for surviving patients was 4.24 years (range, 0.73-8.81 years). Twenty-two of 36 (61%) patients were alive at the time of reporting. Twenty patients were free of disease, and two patients were alive with disease. Fourteen of 36 (39%) patients had died (five of distant metastases, six of local recurrences, two of both local disease and distant metastases, and one of unrelated cause). Patients with rT1 disease (median survival not reached) fared better that patients with rT2 disease (median survival, 4.6 years). The actuarial 5-year disease-free survival and overall survival (OS) were 57% (rT1 78%, rT2 39%) and 62% (rT1 80%, rT2 48%), respectively. The actuarial 5-year local control was 65% (rT1 82%, rT2 49%). The treatment was well tolerated with no significant acute complications. Sixteen patients (44%) had late complications, including palatal fibrosis in six patients (17%), trismus in seven patients (20%), cranial nerve palsies in seven patients (20%), temporal lobe necrosis in two patients (8%), and osteoradionecrosis of the skull base in six patients (17%). The complication-free survival rates at 2 and 5 years were 70% (95% confidence interval [CI], 56% to 87%) and 31% (95% CI, 17% to 56%), respectively. No patient died as a direct result of the late complication. CONCLUSION: Although our series is small, the combination of SRS and ICI seems to be an effective salvage treatment for early-stage recurrent NPC. The OS of 62% at 5 years is very encouraging and favorable compared with reported reirradiation or surgical series. The late complications are considerable but expected because of the high doses of radiation previously delivered. The ideal dose fractionation for SRS and ICI is unknown and remains to be defined.     

Radiosurgical treatment of cavernous sinus meningiomas: experience with 122 treated patients

OBJECTIVE: To evaluate the efficacy of gamma knife (GK) radiosurgery, in terms of neurological improvement and tumor growth control (TGC), for a large series of patients with cavernous sinus meningiomas. METHODS: Between February 1993 and January 2002, 156 patients with cavernous sinus meningiomas (35 male and 121 female patients; mean age, 56.1 yr) were treated with GK radiosurgery in our department. GK radiosurgery was used as a first-choice treatment for 75 of 156 patients and as postoperative adjuvant therapy for 81 of 156 patients (all with Grade I meningiomas). Eligibility criteria for radiosurgery were as follows: symptomatic meningiomas and/or documented tumor progression on magnetic resonance imaging scans, conditions of high operative risk, patient refusal of microsurgery or reoperation, tumor volume of <20 cm(3), and location no less than 2 mm from the optic pathways. RESULTS: Follow-up data for at least 12 months were available for 122 patients (median follow-up period, 48.9 mo). Clinical conditions were improved or stable for 118 of 122 patients (97%). Neurological recovery was observed for 78.5% of patients treated with GK radiosurgery alone and for 60.5% of patients treated with adjuvant therapy (P < 0.05). Adequate TGC was documented for 119 of 122 tumors (97.5%), with shrinkage/disappearance in 75 of 122 cases (61.5%) and no variation in volume in 44 of 122 cases (36%); the overall actuarial progression-free survival rate at 5 years was 96.5%. Tumor size regression was observed for 80% of patients with follow-up periods of more than 30 months, compared with 43.5% of patients with follow-up periods of less than 30 months (P < 0.0002). Radiosurgical sequelae were transient in 4 of 122 cases (3.0%) and permanent in 1 case (1%). CONCLUSION: For the follow-up periods in our series (median, >4 yr), GK radiosurgery seems to be both safe (permanent morbidity rate, 1%) and effective (97% neurological improvement/stability, 97.5% overall TGC, and 96.5% actuarial TGC at 5 yr). GK radiosurgery might be considered a first-choice treatment for selected patients with cavernous sinus meningiomas.     

Radiotherapy in the treatment of benign meningioma of the skull base

OBJECT: This study was undertaken to assess the long-term efficacy and toxicity of conventional fractionated external-beam radiation in the treatment of benign skull base meningioma. METHODS: This is a retrospective study of 82 patients with histologically verified benign skull base meningioma treated by surgery followed by fractionated external-beam radiation at the Royal Marsden Hospital between 1962 and 1992. The 5- and 10-year progression-free survival (PFS) rates were 92% and 83%, respectively, with the site of disease being the only independent prognostic factor for tumor control according to multivariate analysis. The 10-year PFS rate for patients with sphenoid ridge meningiomas was 69% compared with 90% for those with tumors in the parasellar region. The overall 10-year survival rate was 71%, with performance status and patient age found to be significant independent prognostic factors. Six patients had worsening vision, which was due to cataract in five cases and retinopathy in one. There were no recorded cases of cranial nerve neuropathy. CONCLUSIONS: The excellent long-term tumor control and length of survival with minimal toxicity associated with conventional external-beam radiation should serve as a baseline for evaluation of new treatment strategies such as radiosurgery and skull base surgery.     

Treatment of patients with primary glioblastoma multiforme with standard postoperative radiotherapy and radiosurgical boost: prognostic factors and long-term outcome.

OBJECT: To assess the value of stereotactic radiosurgery (SRS) as adjunct therapy in patients suffering from glioblastoma multiforme (GBM), the authors analyzed their experience with 78 patients. METHODS: Between June 1988 and January 1995, 78 patients underwent SRS as part of their initial treatment for GBM. All patients had undergone initial surgery or biopsy confirming the diagnosis of GBM and received conventional external beam radiotherapy. Stereotactic radiosurgery was performed using a dedicated 6-MV stereotactic linear accelerator. Thirteen patients were alive at the time of analysis with a median follow-up period of 40.8 months. The median length of actuarial survival for all patients was 19.9 months. Twelve- and 24-month survival rates were 88.5% and 35.9%, respectively. Patient age and Radiation Therapy Oncology Group (RTOG) class were significant prognostic indicators according to univariate analysis (p < 0.05). Twenty-three patients aged younger than 40 years had a median survival time of 48.6 months compared with 55 older patients who had 18.2 months (p < 0.001). Patients in this series fell into RTOG Classes III (27 patients), IV (29 patients), or V (22 patients). Class III patients had a median survival time of 29.5 months following diagnosis; this was significantly longer than median survival times for Classes IV and V, which were 19.2 and 18.2 months, respectively (p = 0.001). Only patient age (< 40 years) was a significant prognostic factor according to multivariate analysis. Acute complications were unusual and limited to exacerbation of existing symptoms. There were no new neuropathies secondary to SRS. Thirty-nine patients (50%) underwent reoperation for symptomatic necrosis or recurrent tumor. The rate of reoperation at 24 months following SRS was 54.8%. CONCLUSIONS: The addition of a radiosurgery boost appears to confer a survival advantage to selected patients.