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      Stereotactic Radiosurgery for Intracranial Noncavernous Sinus Benign Meningioma: International Stereotactic Radiosurgery Society Systematic Review, Meta-Analysis and Practice Guideline

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          Abstract

          BACKGROUND

          Stereotactic radiosurgery (SRS) for benign intracranial meningiomas is an established treatment.

          OBJECTIVE

          To summarize the literature and provide evidence-based practice guidelines on behalf of the International Stereotactic Radiosurgery Society (ISRS).

          METHODS

          Articles in English specific to SRS for benign intracranial meningioma, published from January 1964 to April 2018, were systematically reviewed. Three electronic databases, PubMed, EMBASE, and the Cochrane Central Register, were searched.

          RESULTS

          Out of the 2844 studies identified, 305 had a full text evaluation and 27 studies met the criteria to be included in this analysis. All but one were retrospective studies. The 10-yr local control (LC) rate ranged from 71% to 100%. The 10-yr progression-free-survival rate ranged from 55% to 97%. The prescription dose ranged typically between 12 and 15 Gy, delivered in a single fraction. Toxicity rate was generally low.

          CONCLUSION

          The current literature supporting SRS for benign intracranial meningioma lacks level I and II evidence. However, when summarizing the large number of level III studies, it is clear that SRS can be recommended as an effective evidence-based treatment option (recommendation level II) for grade 1 meningioma.

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          EANO guidelines for the diagnosis and treatment of meningiomas.

          Kita Sallabanda, Elizabeth Cohen-Jonathan Moyal, Morten Lund-Johansen … (2016)
          Although meningiomas are the most common intracranial tumours, the level of evidence to provide recommendations for the diagnosis and treatment of meningiomas is low compared with other tumours such as high-grade gliomas. The meningioma task force of the European Association of Neuro-Oncology (EANO) assessed the scientific literature and composed a framework of the best possible evidence-based recommendations for health professionals. The provisional diagnosis of meningioma is mainly made by MRI. Definitive diagnosis, including histological classification, grading, and molecular profiling, requires a surgical procedure to obtain tumour tissue. Therefore, in many elderly patients, observation is the best therapeutic option. If therapy is deemed necessary, the standard treatment is gross total surgical resection including the involved dura. As an alternative, radiosurgery can be done for small tumours, or fractionated radiotherapy in large or previously treated tumours. Treatment concepts combining surgery and radiosurgery or fractionated radiotherapy, which enable treatment of the complete tumour volume with low morbidity, are being developed. Pharmacotherapy for meningiomas has remained largely experimental. However, antiangiogenic drugs, peptide receptor radionuclide therapy, and targeted agents are promising candidates for future pharmacological approaches to treat refractory meningiomas across all WHO grades.
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            Radiosurgery as definitive management of intracranial meningiomas.

            Douglas Kondziolka, Douglas Kondziolka, R Madhok … (2008)
            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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              Factors predicting local tumor control after gamma knife stereotactic radiosurgery for benign intracranial meningiomas.

              Vincent C. Arena, Steven DiBiase, Young Kwok … (2004)
              To determine the long-term outcomes and prognostic factors in benign intracranial meningiomas treated with gamma knife stereotactic radiosurgery (GK-SRS). Between 1992 and 2000, 162 patients with benign meningiomas were treated with GK-SRS at the University of Maryland Medical Center. Complete follow-up was available in 137 patients. All patients underwent magnetic resonance imaging (MRI)-based treatment planning. Serial MRIs and clinical exams were performed to assess tumor response. GK-SRS was the primary treatment in 85 patients (62%), whereas 52 patients (48%) had prior surgical resections. The median prescribed dose was 14 Gy (range, 4-25 Gy) to the 50% isodose line. The median tumor volume, treatment volume, and conformity index were 4.5 cc (range, 0.32-80.0 cc), 6.3 cc (range, 1.0-75.2 cc), and 1.34 (range, 0.65-3.16), respectively. The median follow-up for the entire cohort was 4.5 years (range, 0.33-10.5 years). The following factors were included in the statistical analysis for disease-free survival (DFS) and overall survival (OS): sex, age, dose, gross tumor volume (GTV), conformity index (CI), and dural tail coverage. Serial MRI analysis was available in 121 patients (88.3%). Decrease in tumor size was observed in 34 patients (28.1%), whereas there was no change in 77 patients (63.6%), for a crude radiographic control rate of 91.7%. Increase in tumor size was seen in 10 patients (8.3%). New neurologic deficits attributed to the treatment developed in 10 patients (8.3%). The mean DFS and OS for the entire cohort are 4.6 years and 5.0 years, respectively. The 5-year actuarial DFS and OS were 86.2% and 91.0%, respectively. Univariate analysis revealed GTV, sex, CI, and dural tail treatment to be significant prognostic factors. Patients with GTV or =1.4 achieved a longer DFS, with a 5-year DFS of 95.2% vs. 77.3% (p = 0.01). Patients who had the dural tail treated also had higher 5-year DFS (96.0% vs. 77.9%, p = 0.038). Patients with lower conformity (i.e., CI > or =1.4) tended to have the dural tail covered in the prescription isodose line (p = 0.04). The only factor significant in the multivariate analysis was for patients with GTV >10 cc, who had a worse DFS (hazard ratio 4.58, p = 0.05). This report adds to the literature that supports the efficacy and safety of GK-SRS in the management of patients with benign intracranial meningiomas. Our report identified male patients, patients with a CI <1.4, and tumor size greater than 10 cc to have a worse prognosis. Patients who were treated with less conformal plans to cover the dural tail had better outcomes. Our data clearly demonstrate the need to adequately cover the dural tail in patients treated with GK-SRS for benign intracranial meningiomas.
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                Author and article information

                Contributors
                Marcello Marchetti
                Arjun Sahgal
                Antonio A F De Salles
                Marc Levivier
                Lijun Ma
                Ian Paddick:
                ORCID: http://orcid.org/0000-0002-3820-8654
                Bruce E Pollock
                Jean Regis
                Jason Sheehan
                John H Suh
                Shoji Yomo
                Laura Fariselli
                Journal
                Journal ID (nlm-ta): Neurosurgery
                Journal ID (iso-abbrev): Neurosurgery
                Journal ID (publisher-id): neurosurgery
                Title: Neurosurgery
                Publisher: Oxford University Press
                ISSN (Print): 0148-396X
                ISSN (Electronic): 1524-4040
                Publication date Collection: November 2020
                Publication date (Electronic): 28 May 2020
                Publication date PMC-release: 28 May 2020
                Volume: 87
                Issue: 5
                Pages: 879-890
                Affiliations
                Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta , Milano, Italia
                Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto , Toronto, Canada
                HCor Neuroscience Institute, Heart Hospital (HCor) , São Paulo, São Paulo, Brazil
                Neurosurgery Service and Gamma Knife Center Centre Hospitalier Universitaire Vaudois (CHUV) , Lausanne, Switzerland
                Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL) , Lausanne, Switzerland
                Department of Radiation Oncology, University of California San Francisco , San Francisco, California
                Medical Physics Ltd, Queen Square Radiosurgery Centre , London, United Kingdom
                Department of Radiation Oncology and Department of Neurologic Surgery, Mayo Clinic School of Medicine , Rochester, Minnesota
                Stereotactic and Functional Neurosurgery Service and Gamma Knife Unit CHU Timone , Marseille, France
                Department of Neurosurgery, University of Virginia , Charlottesville, Virginia
                Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic , Cleveland, Ohio
                Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital , Matsumoto, Japan
                Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta , Milano, Italia
                Author notes
                Correspondence: Marcello Marchetti, MD, Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Via Celoria 11, 20133 Milan, Italy. Email: marcello.marchetti@ 123456istituto-besta.it
                Author information
                http://orcid.org/0000-0002-3820-8654
                Article
                Publisher ID: nyaa169
                DOI: 10.1093/neuros/nyaa169
                PMC ID: 7566438
                PubMed ID: 32463867
                SO-VID: b6f9b4f3-b463-45c5-bc31-7d4200cb5a72
                Copyright © © Congress of Neurological Surgeons 2020.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence ( http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@ 123456oup.com

                History
                Date received : 13 August 2019
                Date accepted : 12 March 2020
                Page count
                Pages: 12
                Categories
                Subject: Review
                Subject: AcademicSubjects/MED00930
                Subject: Neuros/3
                Subject: Editor's Choice

                Keywords: radiosurgery,multisession-radiosurgery,fractionated radiosurgery,hypofractionated stereotactic radiotherapy,meningioma,guidelines,systematic review
                Data availability:
                Keywords: radiosurgery, multisession-radiosurgery, fractionated radiosurgery, hypofractionated stereotactic radiotherapy, meningioma, guidelines, systematic review

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