Cavernous sinus hemangioma Gamma Knife surgery

Cavernous sinus hemangioma Gamma Knife surgery

A study aimed to evaluate the efficacy of Gamma Knife surgery (GKS) on cavernous sinus hemangioma and to analyze the temporal volume change.

Cho et al. retrospectively reviewed the clinical data of 26 cavernous sinus hemangioma patients who were treated with GKS between 2001 and 2017. Before GKS, 11 patients (42.3%) had cranial neuropathies and 5 patients (19.2%) complained of headache, whereas 10 patients (38.5%) were initially asymptomatic. The mean pre-GKS mass volume was 9.3 mL (range, 0.5-31.6 mL), and the margin dose ranged from 13 to 15 Gy according to the mass volume and the proximity to the optic pathway. All cranial neuropathy patients and half of headache patients showed clinical improvement. All 26 patients achieved mass control; remarkable responses (less than 1/3 of the initial mass volume) were shown in 19 patients (73.1%) and moderate responses (more than 1/3 and less than 2/3) in 7 patients (26.9%). The mean final mass volume after GKS was 1.8 mL (range, 0-12.6 mL). The mean mass volume at 6 months after GKS was 45% (range, 5-80%) compared to the mass volume before GKS and 21% (range, 0-70%) at 12 months. The higher radiation dose tended to induce more rapid and greater volume reduction. No treatment-related complication was observed during the follow-up period. GKS could be an effective and safe therapeutic strategy for CSCH. GKS induced very rapid volume reduction compared to other benign brain tumors 1).


An international multicenter study was conducted to review outcome data in 31 patients with CSH. Eleven patients had initial microsurgery before SRS, and the other 20 patients (64.5%) underwent Gamma Knife SRS as the primary management for their CSH. Median age at the time of radiosurgery was 47 years, and 77.4% of patients had cranial nerve dysfunction before SRS. Patients received a median tumor margin dose of 12.6 Gy (range 12-19 Gy) at a median isodose of 55%. RESULTS Tumor regression was confirmed by imaging in all 31 patients, and all patients had greater than 50% reduction in tumor volume at 6 months post-SRS. No patient had delayed tumor growth, new cranial neuropathy, visual function deterioration, adverse radiation effects, or hypopituitarism after SRS. Twenty-four patients had presented with cranial nerve disorders before SRS, and 6 (25%) of them had gradual improvement. Four (66.7%) of the 6 patients with orbital symptoms had symptomatic relief at the last follow-up. CONCLUSIONS Stereotactic radiosurgery was effective in reducing the volume of CSH and attaining long-term tumor control in all patients at a median of 40 months. The authors’ experience suggests that SRS is a reasonable primary and adjuvant treatment modality for patients in whom a CSH is diagnosed. 2).


Between August 2011 and April 2014, 7 patients with CSHs underwent GKS. GKS was performed as the sole treatment option in 5 patients, whilst partial resection had been performed previously in 1 patient and biopsy had been performed in 1 patient. The mean volume of the tumors at the time of GKS was 12.5±10.2 cm3 (range, 5.3-33.2 cm3), and the median prescription of peripheral dose was 14.0 Gy (range, 10.0-15.0 Gy). The mean follow-up period was 20 months (range, 6-40 months). At the last follow-up, the lesion volume had decreased in all patients, and all cranial neuropathies observed prior to GKS had improved. There were no radiation-induced neuropathies or complications during the follow-up period. GKS appears to be an effective and safe treatment modality for the management of CSHs 3).


A retrospective analysis of 7 patients with CS hemangiomas treated by GKS between 1993 and 2008. Data from 84 CS meningiomas treated during the same period were also analyzed for comparison. The patients underwent follow-up magnetic resonance imaging at 6-month intervals. Data on clinical and imaging changes after radiosurgery were analyzed.

Six months after GKS, magnetic resonance imaging revealed an average of 72% tumor volume reduction (range, 56%-83%). After 1 year, tumor volume decreased 80% (range, 69%-90%) compared with the pre-GKS volume. Three patients had > 5 years of follow-up, which showed the tumor volume further decreased by 90% of the original size. The average tumor volume reduction was 82%. In contrast, tumor volume reduction of the 84 cavernous sinus meningiomas after GKS was only 29% (P < .001 by Mann-Whitney U test). Before treatment, 6 patients had various degrees of ophthalmoplegia. After GKS, 5 improved markedly within 6 months. Two patients who suffered from poor vision improved after radiosurgery.

GKS is an effective and safe treatment modality for CS hemangiomas with long-term treatment effect. Considering the high risks involved in microsurgery, GKS may serve as the primary treatment choice for CS hemangiomas 4).


1)

Cho JM, Sung KS, Jung IH, Chang WS, Jung HH, Chang JH. Temporal Volume Change of Cavernous Sinus Cavernous Hemangiomas after Gamma Knife Surgery. Yonsei Med J. 2020 Nov;61(11):976-980. doi: 10.3349/ymj.2020.61.11.976. PMID: 33107242.
2)

Lee CC, Sheehan JP, Kano H, Akpinar B, Martinez-Alvarez R, Martinez-Moreno N, Guo WY, Lunsford LD, Liu KD. Gamma Knife radiosurgery for hemangioma of the cavernous sinus. J Neurosurg. 2017 May;126(5):1498-1505. doi: 10.3171/2016.4.JNS152097. Epub 2016 Jun 24. PMID: 27341049.
3)

Xu Q, Shen J, Feng Y, Zhan R. Gamma Knife radiosurgery for the treatment of cavernous sinus hemangiomas. Oncol Lett. 2016 Feb;11(2):1545-1548. doi: 10.3892/ol.2015.4053. Epub 2015 Dec 23. PMID: 26893777; PMCID: PMC4734249.
4)

Chou CW, Wu HM, Huang CI, Chung WY, Guo WY, Shih YH, Lee LS, Pan DH. Gamma knife surgery for cavernous hemangiomas in the cavernous sinus. Neurosurgery. 2010 Sep;67(3):611-6; discussion 616. doi: 10.1227/01.NEU.0000378026.23116.E6. PMID: 20647963.

Cerebellopontine Angle Synchronous Tumor

Cerebellopontine Angle Synchronous Tumor

Synchronous cerebellopontine angle (CPA) tumors are a rare entity, heterogeneous lesions with a marked predisposition toward poor facial nerve outcomes, potentially attributable to a paracrine mechanism that simultaneously drives multiple tumor growth and increases invasiveness or adhesiveness at the facial nerve-tumor interface. Preceding nomenclature has been confounding and inconsistent; Graffeo et al. recommended classifying all multiple CPA tumors as “synchronous tumors,” with “schwannoma with meningothelial hyperplasia” or “tumor-to-tumor metastases” reserved for rare, specific circumstances 1).

Several publications refer to surgery for such tumors and their classification. Yet, there are no publications on upfront radiosurgery for synchronous CPA tumors.

Simultaneous and stepwise radiosurgery for synchronous CPA tumors seems to be safe and effective. There were no side effects or complications. To the best of our knowledge this is the first report on upfront radiosurgery for synchronous CPA tumors 2).

Mindermann and Heckl presented two patients with sporadic synchronous benign CPA tumors who underwent upfront radiosurgery. One patient had two separate schwannomas of the CPA and the other had a cerebellopontine angle schwannoma and a cerebellopontine angle meningioma. One patient underwent stepwise radiosurgery treating one tumor after another and the other patient underwent simultaneous radiosurgery for both tumors at the same time.

Simultaneous and stepwise radiosurgery for synchronous CPA tumors seems to be safe and effective. There were no side effects or complications. To the best of our knowledge this is the first report on upfront radiosurgery for synchronous CPA tumors 3).


A 64-year-old woman and a 42-year-old man presented with symptoms referable to the CPA. Magnetic resonance imaging in both patients revealed 2 separate contiguous tumors. Retrosigmoid craniotomy and tumor removal in each case confirmed VS and meningioma. Systematic literature review identified 42 previous English-language publications describing 46 patients with multiple CPA tumors. Based on Frassanito criteria, there were 4 concomitant tumors (8%), 16 contiguous tumors (33%), 3 collision tumors (6%), 13 mixed tumors (27%), and 11 tumor-to-tumor metastases (23%). Extent of resection was gross total in 16 cases and subtotal in 16 cases (50% each). Unfavorable House-Brackmann grade III-VI function was documented in 27% overall and in 33% of patients with VS and meningioma, a marked increase from the observed range in isolated VS 4).


A 57-year-old female patient presented with headache, speech disturbance, left facial numbness and deafness in the left ear. Magnetic resonance imaging demonstrated two different tumors in the left CPA. These tumors were not in continuity. The tumors were totally removed through the left suboccipital approach. Histopathological examination revealed that the large tumor was a vestibular schwannoma and the smaller was a meningioma. Neurofibromatosis was not diagnosed in the patient. No recurrence was observed at the end of 9 years after the operation. The simultaneous occurrence of vestibular schwannoma and meningioma in the CPA appears coincidental. This association must be kept in mind if two different tumors are detected radiologically in the same CPA 5).


1) , 4)

Graffeo CS, Perry A, Copeland WR 3rd, Giannini C, Neff BA, Driscoll CL, Link MJ. Synchronous Tumors of the Cerebellopontine Angle. World Neurosurg. 2017 Feb;98:632-643. doi: 10.1016/j.wneu.2016.11.002. Epub 2016 Nov 12. PMID: 27836701.
2) , 3)

Mindermann T, Heckl S. Radiosurgery for Sporadic Benign Synchronous Tumors of the Cerebellopontine Angle. J Neurol Surg A Cent Eur Neurosurg. 2020 Oct 21. doi: 10.1055/s-0040-1714424. Epub ahead of print. PMID: 33086420.
5)

Izci Y, Secer HI, Gönül E, Ongürü O. Simultaneously occurring vestibular schwannoma and meningioma in the cerebellopontine angle: case report and literature review. Clin Neuropathol. 2007 Sep-Oct;26(5):219-23. doi: 10.5414/npp26219. PMID: 17907598.

IntuitivePlan

IntuitivePlan

http://www.intuitivetherapeutics.com/index.php/en/


Levivier et al. developed a new, real-time interactive inverse planning approach, based on a fully convex framework, to be used for Gamma Knife radiosurgery.

The convex framework is based on the precomputation of a dictionary composed of the individual dose distributions of all possible shots, considering all their possible locations, sizes, and shapes inside the target volume. The convex problem is solved to determine the plan, i.e., which shots and with which weights, that will actually be used, considering a sparsity constraint on the shots to fulfill the constraints while minimizing the beam-on time. The system is called IntuitivePlan and allows data to be transferred from generated dose plans into the Gamma Knife treatment planning software for further dosimetry evaluation.

The system has been very efficiently implemented, and an optimal plan is usually obtained in less than 1 to 2 minutes, depending on the complexity of the problem, on a desktop computer or in only a few minutes on a high-end laptop. Dosimetry data from 5 cases, 2 meningiomas and 3 vestibular schwannomas, were generated with IntuitivePlan. Results of evaluation of the dosimetry characteristics are very satisfactory and adequate in terms of conformity, selectivity, gradient, protection of organs at risk, and treatment time.

The possibility of using optimal, interactive real-time inverse planning in conjunction with the Leksell Gamma Knife opens new perspectives in radiosurgery, especially considering the potential use of the full capabilities of the latest generations of the Leksell Gamma Knife. This approach gives new users the possibility of using the system for easier and quicker access to good-quality plans with a shorter technical training period and opens avenues for new planning strategies for expert users. The use of a convex optimization approach allows an optimal plan to be provided in a very short processing time. This way, innovative graphical user interfaces can be developed, allowing the user to interact directly with the planning system to graphically define the desired dose map and to modify on-the-fly the dose map by moving, in a very user-friendly manner, the isodose surfaces of an initial plan. Further independent quantitative prospective evaluation comparing inverse planned and forward planned cases is warranted to validate this novel and promising treatment planning approach 1).


To compare planning indices achieved using manual and inverse planning approaches for Gamma knife radiosurgery for arteriovenous malformation.

For a series of consecutive AVM patients, treatment plans were manually created by expert planners using Leksell GammaPlan (LGP). Patients were re-planned using a new commercially released inverse planning system, IntuitivePlan. Plan quality metrics were calculated for both groups of plans and compared.

Overall, IntuitivePlan created treatment plans of similar quality to expert planners. For some plan quality metrics statistically significant higher scores were achieved for the inversely generated plans (Coverage 96.8% vs 96.3%, P = 0.027; PCI 0.855 vs 0.824, P = 0.042), but others did not show statistically significant differences (Selectivity 0.884 vs 0.856, P = 0.071; GI 2.85 vs 2.76, P = 0.096; Efficiency Index 47.0% vs 48.1%, P = 0.242; Normal Brain V12 (cc) 5.81 vs 5.79, P = 0.497). Automatic inverse planning demonstrated significantly shorter planning times over manual planning (3.79 vs 11.58 min, P < 10-6 ) and greater numbers of isocentres (40.4 vs 10.8, P < 10-6 ), with an associated cost of longer treatment times (57.97 vs 49.52 min, P = 0.009). When planning and treatment time were combined, there was no significant difference in the overall time between the two methods (61.76 vs 61.10, P = 0.433).

IntuitivePlan can offer savings on the labor of treatment planning. In many cases, it achieves higher quality indices than those achieved by an “expert planner” 2).

References

1)

Levivier M, Carrillo RE, Charrier R, Martin A, Thiran JP. A real-time optimal inverse planning for Gamma Knife radiosurgery by convex optimization: description of the system and first dosimetry data. J Neurosurg. 2018;129(Suppl1):111-117. doi:10.3171/2018.7.GKS181572
2)

Paddick I, Grishchuk D, Dimitriadis A. IntuitivePlan inverse planning performance evaluation for Gamma Knife radiosurgery of AVMs [published online ahead of print, 2020 Aug 4]. J Appl Clin Med Phys. 2020;10.1002/acm2.12973. doi:10.1002/acm2.12973
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