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      Image-Guided Multisession Radiosurgery of Skull Base Meningiomas

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          Abstract

          Simple Summary

          Stereotactic radiosurgery has changed the landscape of treatment for skull base meningiomas. Lesions encasing or compressing radiosensitive structures are considered not suitable for single session stereotactic radiosurgery because of the high risk of side effects. Multisession stereotactic radiosurgery can reduce these risks, allowing for normal tissue repair between fractions, while delivering a high dose per fraction. The aim of this study is to validate the role of multi-session stereotactic radiosurgery in the treatment of skull base meningiomas, through a retrospective analysis of 156 patients affected by skull base meningioma, treated at the University of Messina between 2008 and 2018. Our study suggests that multisession stereotactic radiosurgery represents a safe and effective profile in the treatment of skull base meningioma, providing a satisfactory local control and a low toxicity rate, together with patient comfort from a frameless procedure.

          Abstract

          Background: The efficacy of single-session stereotactic radiosurgery (sSRS) for the treatment of intracranial meningioma is widely recognized. However, sSRS is not always feasible in cases of large tumors and those lying close to critically radiation-sensitive structures. When surgery is not recommended, multi-session stereotactic radiosurgery (mSRS) can be applied. Even so, the efficacy and best treatment schedule of mSRS are not yet established. The aim of this study is to validate the role of mSRS in the treatment of skull base meningiomas. Methods: A retrospective analysis of patients with skull base meningiomas treated with mSRS (two to five fractions) at the University of Messina, Italy, from 2008 to 2018, was conducted. Results: 156 patients met the inclusion criteria. The median follow-up period was 36.2 ± 29.3 months. Progression-free survival at 2-, 5-, and 10- years was 95%, 90%, and 80.8%, respectively. There were no new visual or motor deficits, nor cranial nerves impairments, excluding trigeminal neuralgia, which was reported by 5.7% of patients. One patient reported carotid occlusion and one developed brain edema. Conclusion: Multisession radiosurgery is an effective approach for skull base meningiomas. The long-term control is comparable to that obtained with conventionally-fractionated radiotherapy, while the toxicity rate is very limited.

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          Most cited references53

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          A simple scoring ratio to index the conformity of radiosurgical treatment plans

          ✓ A conformity index is a measure of how well the volume of a radiosurgical dose distribution conforms to the size and shape of a target volume. Because the success of radiosurgery is related to the extremely conformal irradiation of the target, an accurate method for describing this parameter is important. Existing conformity ratios and indices used in radiosurgery are reviewed and criticized. It will be demonstrated that previously proposed measurements of conformity can, under certain conditions, give false perfect scores. A new conformity index is derived that gives an objective score of conformity for a treatment plan and gives no false scores. An analysis of five different treatment plans is made using both the existing scoring methods and the new conformity index.
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            Radiosurgery as definitive management of intracranial meningiomas.

            Stereotactic radiosurgery has become an important primary or adjuvant minimally invasive management strategy for patients with intracranial meningiomas with the goals of long-term tumor growth prevention and maintenance of patient neurological function. We evaluated clinical and imaging outcomes of meningiomas stratified by histological tumor grade. The patient cohort consisted of 972 patients with 1045 intracranial meningiomas managed during an 18-year period. The series included 70% women, 49% of whom had undergone a previous resection and 5% of whom had received previous fractionated radiation therapy. Tumor locations included middle fossa (n = 351), posterior fossa (n = 307), convexity (n = 126), anterior fossa (n = 88), parasagittal region (n = 113), or other (n = 115). The overall control rate for patients with benign meningiomas (World Health Organization Grade I) was 93%. In those without previous histological confirmation (n = 482), tumor control was 97%. However, for patients with World Health Organization Grade II and III tumors, tumor control was 50 and 17%, respectively. Delayed resection after radiosurgery was necessary in 51 patients (5%) at a mean of 35 months. After 10 years, Grade 1 tumors were controlled in 91% (n = 53); in those without histology, 95% (n = 22) were controlled. None of the patients developed a radiation-induced tumor. The overall morbidity rate was 7.7%. Symptomatic peritumoral imaging changes developed in 4% of the patients at a mean of 8 months. Stereotactic radiosurgery provided high rates of tumor growth control or regression in patients with benign meningiomas with low risk. This study confirms the role of radiosurgery as an effective management choice for patients with small to medium-sized symptomatic, newly diagnosed or recurrent meningiomas of the brain.
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              Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas.

              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. 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%. 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).
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                Author and article information

                Journal
                Cancers (Basel)
                Cancers (Basel)
                cancers
                Cancers
                MDPI
                2072-6694
                29 November 2020
                December 2020
                : 12
                : 12
                : 3569
                Affiliations
                [1 ]Unit of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; matteo.zoli4@ 123456unibo.it (M.Z.); diego.mazzatenta@ 123456unibo.it (D.M.)
                [2 ]Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; filippo.friso@ 123456studio.unibo.it (F.F.); vittoria.rosetti@ 123456studio.unibo.it (V.R.)
                [3 ]Department of Radiation Oncology, BIOMORF, University of Messina, via Consolare Valeria 1, 98122 Messina, Italy; apontoriero@ 123456unime.it (A.P.); giuseppe.iati@ 123456polime.it (G.I.); anna.brogna@ 123456polime.it (A.B.); sparisi@ 123456unime.it (S.P.); alberto.cacciola0@ 123456gmail.com (A.C.); slillo@ 123456unime.it (S.L.); Stefano.pergolizzi@ 123456polime.it (S.P.)
                [4 ]Department of Neurosurgery, BIOMORF, University of Messina, via Consolare Valeria 1, 98122 Messina, Italy; salvatore.cardali@ 123456unime.it
                Author notes
                Author information
                https://orcid.org/0000-0003-1333-9882
                https://orcid.org/0000-0001-8838-5408
                https://orcid.org/0000-0001-9135-1639
                https://orcid.org/0000-0001-9412-4116
                Article
                cancers-12-03569
                10.3390/cancers12123569
                7761100
                33260363
                36f7682c-0bb5-4b2a-9aaf-59d19968c5a5
                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 08 November 2020
                : 27 November 2020
                Categories
                Article

                meningioma,skull base,radiosurgery,image-guided radiotherapy,hypofractionated stereotactic radiotherapy,cyberknife

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