Strahlentherapie bei Meningeom

[Ulrich]

Vorausgesetzt, das M. ist operativ gut zugänglich, dann ist wohl immer eine Operation das Mittel der ersten Wahl.

Eine Bestrahlung trifft und schädigt hauptsächlich schnellwachsende Zellen, solche sind aber bei einem benignen, langsam wachsenden Meningeom (WHO I-II) kaum vorhanden.
Eine Bestrahlung dürfte bei einem Meningeom also nur dann zu erwägen sein, wenn a) das M. inoperabel ist und / oder b) auch maligne Anteile enthalten sind.

Zur Information hier einige Artikel über Strahlentherapie bei Meningeomen. Alles, was mir zu diesem Thema "zwischen die Finger gerät" und mir sinnvoll erscheint, werde ich hier einbauen. Es tut mir leid, wenn englische und deutsche Texte durcheinandergehen und die Lesbarkeit erschweren. Es wäre zu viel Aufwand, jeden Text zu übersetzen. Auf Anfrage (und wenn ich's kann) würde ich den einen oder anderen Text auch noch übersetzen.

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Stereotaktische Bestrahlung von Patienten mit Meningeom (eine Dissertation der Uni Heidelberg)

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Radiotherapie von gutartigen Tumoren und arteriovenösen Fehlbildungen des Zentralnervensystems.

Dieser Artikel wurde über "medline" recherchiert, von ihm ist nur eine Zusammenfassung vorhanden. Bei Bedarf müßten Sie sich den Originalartikel (Volltext) in einer Universitätsbibliothek besorgen.

Hier eine Übersetzung der Zusammenfassung:
Nach [einer Verlaufskontrolle von] 5 Jahren scheint die einmalige stereotaktische Bestrahlung, entweder allein oder zusammen mit einer unvollständigen chirurgischen Entfernung, zu Ergebnissen zu führen, die vergleichbar sind mit solchen, die bei einer kompletten Entfernung des Meningeoms gefunden werden, nämlich einer rezidiv-freien Zeit von 90% oder darüber. Die Komplikationsrate ist klein, wenigstens dann, wenn die Strahlungsdosen in der Nähe von kritischen Strukturen (wie zum Beispiel dem optischen Apparat) kleiner sind als 8 Gy bei einer einmaligen Bestrahlung. Stereotaktische Radiotherapie ist eine Alternative mit geringer Toxizität für Meningeome größer als 3 cm oder für solche nahe den optischen Nerven oder anderen sensiblen Bereichen, obwohl die vorhandenen Daten über die Wirksamkeit und Sicherheit noch gering sind. Weil es noch keine Langzeitstudien für die stereotaktische Radiotherapie gibt, bleibt die chirurgische Entfernung von gutartigen Meningeomen die erste Wahl einer Behandlung.

Front Radiat Ther Oncol 2001;35:30-47
Radiosurgery for benign tumors and arteriovenous malformations of the central nervous system.

Hartford AC, Loeffler JS.

Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, Mass., USA.

At 5 years, single-fraction stereotactic radiosurgery, alone or in conjunction with subtotal surgical resection, appears to yield local control rates that are comparable to those achieved by complete resection of the meningioma, with progression-free survival at or above 90%. Complication rates are low, as long as doses to critical structures, particularly to the optic apparatus, are maintained below 8.0 Gy in a single fraction. Stereotactic radiotherapy is an alternative treatment with low rates of toxicity for meningiomas in excess of 3.0 cm size, or for those near the optic nerves or other sensitive areas, although follow-up data for treatment efficacy and safety are still very short for this fractionated technique. Given the lack of available long-term follow-up data for stereotactic radiosurgery, complete surgical resection remains the optimal, first choice of treatment for benign meningiomas.

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Die Rolle der Strahlentherapie in der Behandlung von Meningeomen

Dieser Artikel wurde über "medline" recherchiert, von ihm ist nur eine Zusammenfassung vorhanden. Bei Bedarf müssen Sie sich den Originalartikel in einer Universitätsbibliothek besorgen. Der Originalartikel ist auf französisch verfaßt.

Hier eine Übersetzung der englischen Zusammenfassung, die dann weiter unten im Original folgt:

Cerebrale Meningeome machen etwa 15-20% aller Gehirntumoren aus. Obwohl sie selten bösartig sind, rezidivieren sie doch häufig trotz kompletter operativer Entfernung, der wichtigsten Behandlungsart. Um die Wahrscheinlichkeit eines örtlichen Rezidivs zu vermindern, wurde oft die Strahlentherapie empfohlen und zwar sowohl bei atypischen und malignen [bösartigen] Meningeomen als auch bei gutartigen Meningeomen, die unvollständig entfernt wurden. Dieses Vorgehen war bisher niemals Gegenstand von Studien, die den Verlauf voraussagten [prospektiven Studien]. Der Zweck dieser Literaturübersicht ist es, einen Fortschrittsbericht zu verfassen über die Ergebnisse der verschiedenen veröffentlichten Untersuchungen über die Methoden und die Techniken der Strahlentherapie. Auf unsere Analyse lassen wir Empfehlungen folgen für die geeignete therapeutische Wahl. Für Meningeome Grad I bzw. Grad II-III werden die Grenzen des "Brutto-Tumor-Volumens" [GTV = gross tumor volume] definiert als der Tumor am Ort bzw. der Resttumor nach der Operation. Das "klinische Zielvolumen" [CTV = clinical target volume] entspricht dem GTV mit einem Sicherheitssaum [frei übersetzt] von 1 cm bei Grad I bzw. 2 cm bei Grad II-III. Die Strahlendosen sind 55 Gy in das CTV und ins GTV sind es 55-60 Gy für Grad I und 70 Gy  bei Grad II-II Meningeomen.

Cancer Radiother 2001 Jun;5(3):217-36
Role of radiotherapy in the treatment of cerebral meningiomas

[Article in French]

Noel G, Renard A, Valery C, Mokhtari K, Mazeron JJ.

Centre de protontherapie d'Orsay, BP 65, 91402 Orsay, France. noel@ipno.in2p3.fr

Cerebral meningiomas account for 15-20% of all cerebral tumours. Although seldom malignant, they frequently recur in spite of complete surgery, which remains the cornerstone of the treatment. In order to decrease the probability of local recurrence, radiotherapy has often been recommended in atypical or malignant meningioma as well as in benign meningioma which was incompletely resected. However, this treatment never was the subject of prospective studies, randomized or not. The purpose of this review of the literature was to give a progress report on the results of different published series in the field of methodology as well as in the techniques of radiotherapy. Proposals for a therapeutic choice are made according to this analysis. For grade I or grade II-III meningiomas, limits of gross tumor volume (GTV) include the tumour in place or the residual tumour after surgery; clinical target volume (CTV) limits include gross tumour volume before surgery with a GTV-CTV distance of 1 and 2 cm respectively. Delivered doses are 55 Gy into CTV and 55-60 Gy and 70 Gy into GTV for grade I and grade II-III meningiomas respectively.

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Fraktionierte Radiotherapie von intrakraniellen Meningeomen und Neurinomen.

Dieser Artikel wurde über "medline" recherchiert, von ihm ist nur eine Kurzfassung vorhanden. Bei Bedarf müßten Sie sich den Originalartikel (Volltext) in einer Universitätsbibliothek besorgen und kopieren.

Die Originalarbeit ist auf Französisch verfasst. Hier eine Übersetzung der Zusammenfassung:

In den meisten Kliniken ist die Standardbehandlung von Meningeomen und Neurinomen deren chirurgische Entfernung; das Ziel des chirurgischen Eingriffs ist die völlige Resektion. Die komplette Entfernung ist nicht immer risikolos durchführbar [korrekt übersetzt: nicht ohne erhebliche Sterblichkeit, significant morbidity] und in einigen Fällen verbietet die Verfassung des Patienten eine Operation. Im Fall von unvollständig entfernten Tumoren können Rezidive Auswirkungen auf neurologische Funktionen haben. Es gibt nun eine Reihe von Berichten in der Literatur, die die Tatsache bestätigen, daß eine Strahlentherapie das Auftreten von Rezidiven bei unvollständig entfernten Tumoren vermindert und daß sie die operative Entfernung [des Tumors] sogar ersetzen kann in solchen Fällen, wo eine Operation zu riskant wäre [frei übersetzt] oder dauernde neurologische Schäden anrichten könnte: etwa 80 bis 90% solcher Tumoren lassen sich mit einer Strahlentherapie beherrschen. Stereotaktische und dreidimensionale Planungstechniken verbessern die räumliche Begrenzung [der Bestrahlung] und diese wird dadurch auch vom Zentralnervensystem besser toleriert. Durch diese Verbesserungen muß der Stellenwert von Operation bzw. Radiotherapie neu bestimmt [abgewogen] werden, wobei sowohl Effizienz als auch Komplikationsrate [Sterblichkeit] in die Überlegungen einbezogen werden müssen. In unserem Artikel begrenzen wir unsere Bemerkungen auf die fraktionierte Radiotherapie, wir geben einen Überblick über die Literatur und diskutieren die Indikation [Heilanzeige], Überlegungen zum Volumen [des Tumors] und die Techniken, die derzeit benützt werden.

Fractionated radiotherapy of intracranial meningiomas and neurinomas

[Article in French]

Cancer Radiother 2000 Nov;4 Suppl 1:84s-94s
Maire JP, Vendrely V, Dautheribes M, Bonichon N, Darrouzet V.

Service d'oncologie-radiotherapie, hopital Saint-Andre, 1, rue Jean-Burguet, 33075 Bordeaux, France. jean-philippe.maire@chu-bordeaux.fr

In most institutions, surgical excision remains the standard treatment of meningiomas and neurinomas; the aim of surgery is complete resection. However, total removal is not always feasible without significant morbidity and in some cases, the patient's condition contraindicates surgery. For incompletely excised tumors, recurrences will have consequences on neurological functions. There are now many reports in the literature confirming the fact that radiotherapy significantly decreases the incidence of recurrence of incompletely resected benign tumors and that it can replace surgery in some situations where an operation would involve considerable danger or permanent neurological damage: about 80 to 90% of such tumors are controlled with fractionated radiotherapy. Stereotaxic and three-dimensional treatment planning techniques increase local control and central nervous system tolerance so that the respective place of surgery and radiotherapy needs to be redefined, considering efficacy and morbidity of these two therapeutic means. In this article, we limit our remarks to fractionated radiotherapy and, after a review of the literature, we discuss the indications, volume evaluations and the techniques currently used.

[Ulrich]

Zur Strahlentherapie gehört auch die "Gamma-Knife"-Behandlung:
Hier zunächst zwei LINKs zu einer deutschen Gamma-Knife-Seite (Krefeld):
http://www.gamma-knife.de

und zu einer langen Reihe von Literaturzitaten:
http://www.gamma-knife.de/html/literatur.html

Siehe auch hier:
http://www.gammaknife.de/behandlung/krankheiten/meningeome/index.htm

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Hier ein Artikel zur Behandlung von Meningeomen mit Gamma-Knife:

Der Artikel wurde über medline recherchiert. Beachten Sie: "knife" bedeutet zwar "Messer", es handelt sich aber um eine Strahlentherapie und nicht um eine Operation.

Int J Radiat Oncol Biol Phys 2002 Jul 15;53(4):992-1000
 
The role of Gamma Knife radiosurgery in the management of cavernous sinus meningiomas.

Nicolato A, Foroni R, Alessandrini F, Maluta S, Bricolo A, Gerosa M.
Department of Neurosurgery, University Hospital, Verona, Italy. antonio.nicolato@mail.azosp.vr.it

PURPOSE: To evaluate the efficacy of Gamma Knife (GK) radiosurgery in terms of neurologic improvement and tumor growth control (TGC) in a large series of patients with cavernous sinus meningioma (CSM).

METHODS AND MATERIALS: One hundred thirty-eight patients with CSM (28 males, 110 females; mean age: 56.2 years) were treated with GK between February 1993 and February 2001. GK was used as a first-choice treatment in 68/138 patients and as postoperative adjuvant therapy in 70/138. In 32 patients, it was possible to compare the size of the planned treatment volume to tumor volume using the conformity index (CI); optimal CI values were taken to be < or =1.5 (range: 0.94-2.24). RESULTS: A follow-up (FU) period of at least 12 months was available for 111 patients (median: 48.2 months, range: 12.1-84.5 months). Clinical conditions were improved or stable in 107/111 patients (96.5%). Neurologic recovery was observed in 76% of cases treated by GK alone and in 56.5% of adjuvant treatments (p < 0.03). Adequate TGC was documented in 108/111 tumors (97%), with shrinkage/disappearance in 70/111 (63%) and no variation in volume in 38/111 (34%); the overall actuarial progression-free survival rate at 5 years was 96%. Tumor size regression was observed in 79.5% of patients with FU >30 months, compared with 47.5% of patients with FU <30 months (p < 0.001). One hundred percent TGC was shown in treated patients with a CI < or =1.5 (20/32), compared with 92% TGC in cases with a CI >1.5 (p < 0.15, NS). Radiosurgical sequelae were transient in 4/111 cases (3.5%) and permanent in one case (1%).

CONCLUSIONS: For the FU period of our series (median: >4 years), GK radiosurgery seems to be both safe (permanent morbidity 1%) and effective (96% neurologic improvement/stability, 97% overall TGC, 96% actuarial TGC at 5 years) and might be considered as a first-choice treatment for selected patients with CSM.
 
 

[Ulrich]

Hier ein englischer Artikel über stereotaktische Bestrahlung von Meningeomen:

Der Artikel wurde über "medline" recherchiert. Von ihm ist nur diese Kurzfassung vorhanden.

J Neurosurg 2002 Jul;97(1):65-72

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

Lee JY, Niranjan A, McInerney J, Kondziolka D, Flickinger JC, Lunsford LD.
Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania, USA.

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).

[Ulrich]

Hier noch ein LINK zu einer schweizerischen Seite, die mit Protonenbestrahlung ein wirklich eindrucksvolles Ergebnis bei einem Meningeom zwischen den Augen publiziert hat:

[Ulrich]

Hier fand ich noch einen ganz interessanten Artikel, der Auskunft über die Langzeitwirkung einer Bestrahlung gibt:

Long-Term Outcomes after Meningioma Radiosurgery: Physician and Patient Perspectives

Douglas Kondziolka, M.D., M.Sc., FRCS(C), Elad I. Levy, M.D., Ajay Niranjan, M.Ch., John C. Flickinger, M.D., L. Dade Lunsford, M.D.

Published in Journal of Neurosurgery 91:44-50,1999.

Correspondence:
Douglas Kondziolka, M.D.
Professor of Neurological Surgery
UPMC Presbyterian
Suite B-400, 200 Lothrop Street
Pittsburgh, PA 15213
Telephone: 412-647-6782
Fax: 412-647-0989
E-mail: kondziolkads@msx.upmc.edu


Abstract

Object: Stereotactic radiosurgery is a primary or adjuvant management approach to patients with intracranial meningiomas. The goal of radiosurgery is long-term prevention of tumor growth, maintenance of patient neurologic function, and prevention of new neurological deficits. The object of this study is to report longer-term patient outcomes.

Methods: We evaluated 99 consecutive meningioma patients who underwent radiosurgery between 1987 and 1992 using serial imaging tests, clinical evaluations, and a patient survey between five and ten years later. Four patients had two radiosurgery procedures for separate meningiomas. The average tumor margin dose was 16 Gy and the median tumor volume was 4.7 ml (range, 0.24-24). Fifty-seven patients (57%) had prior resection of which 12 were considered "total". Five patients received fractionated radiation therapy before radiosurgery. Eighty-nine patients (89%) had skull base tumors.

Results: The clinical tumor control rate (no resection required) was 93%. Sixty-one tumors were smaller (63%), 31 remained unchanged in size (32%), and 5 enlarged (5%). Resection was performed in 7 patients (7%), six of whom had prior resection. New neurological deficits developed in five patients (5%), 3 to 31 months after radiosurgery. Twenty-seven patients (42%) were employed at the time of radiosurgery and 20 (74%) remained so. Radiosurgery was believed "successful" by 67 of 70 patients who competed an outcomes questionnaire 5 to 10 ten years later. At least one complication was described by 9 patients (13%) and in four these resolved.

Conclusions: Five to ten years after radiosurgery, 96% of surveyed patients believed that radiosurgery provided a satisfactory outcome for their meningioma. Overall, 93% of patients required no other tumor surgery. Morbidity in this early experience was usually transitory, and relatively mild. Radiosurgery provided long-term tumor control associated with high rates of neurologic function preservation and patient satisfaction.

Den kompletten Artikel finden Sie hier:
http://www.neurosurgery.pitt.edu/imageguided/papers/perspectives.html

[Ulrich]

Neurosurgery 2003 Mar;52(3):517-24

Gamma knife radiosurgery for the treatment of cavernous sinus meningiomas.

Iwai Y, Yamanaka K, Ishiguro T.
Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan.

OBJECTIVE:
We report on the efficacy of gamma knife radiosurgery for cavernous sinus meningiomas.

METHODS:
Between January 1994 and December 1999, we used gamma knife radiosurgery for the treatment of 43 patients with cavernous sinus meningiomas. Forty-two patients were followed up for a mean of 49.4 months (range, 18-84 mo). The patients´ average age was 55 years (range, 18-81 yr). Twenty-two patients (52%) underwent operations before radiosurgery, and 20 patients (48%) underwent radiosurgery after the diagnosis was made by magnetic resonance imaging. The tumor volumes ranged from 1.2 to 101.5 cm(3) (mean, 14.7 cm(3)). The tumors either compressed or were attached to the optic apparatus in 17 patients (40.5%). The marginal radiation dose was 8 to 15 Gy (mean, 11 Gy), and the optic apparatus was irradiated with 2 to 12 Gy (mean, 6.2 Gy). Three patients with a mean tumor diameter greater than 4 cm were treated by two-stage radiosurgery.

RESULTS:
Thirty-eight patients (90.5%) demonstrated tumor growth control during the follow-up period after radiosurgery. Tumor regression was observed in 25 patients (59.5%), and growth was unchanged in 13 patients (31%). Regrowth or recurrence occurred in four patients (9.5%). The actual tumor growth control rate at 5 years was 92%. Only one patient (2.4%) experienced regrowth within the treatment field; in other patients, regrowth occurred at sites peripheral to or outside the treatment field. Twelve patients (28.6%) had improved clinically by the time of the follow-up examination. None of the patients experienced optic neuropathy caused by radiation injury or any new neurological deficits after radiosurgery.

CONCLUSION:
Gamma knife radiosurgery may be a useful option for the treatment of cavernous sinus meningiomas not only as an adjuvant to surgery but also as an alternative to surgical removal. We have shown it to be safe and effective even in tumors that adhere to or are in close proximity to the optic apparatus.

[Ulrich]

Neurosurgery 2002 Oct;51(4):890-904

Fractionated Stereotactic Radiotherapy for the Treatment of Optic Nerve Sheath Meningiomas: Preliminary Observations of 33 Optic Nerves in 30 Patients with Historical Comparison to Observation with or without Prior Surgery.

Andrews DW, Faroozan R, Yang BP, Hudes RS, Werner-Wasik M, Kim SM, Sergott RC, Savino PJ, Shields J, Shields C, Downes MB, Simeone FA, Goldman HW, Curran WJ JR, WJ.
Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

OBJECTIVE:
We investigated the safety and efficacy of stereotactic radiotherapy as an alternative therapy to surgical resection for optic nerve sheath meningiomas (ONSMs).

METHODS:
Thirty patients and 33 optic nerves with ONSMs were treated with conventional fractionated stereotactic radiotherapy treatment (CF-SRT) between July 1996 and May 2001 with the use of a 6-MeV LINAC designed for and dedicated to radiosurgery. The LINAC technique involved daily CF-SRT involving a relocatable frame, an average of three isocenters, and high-radiation dose conformality established by noncoplanar arc beam shaping and differential beam weighting. The patients who were treated with CF-SRT were followed clinically with serial visual fields and radiographically with both magnetic resonance imaging and functional (111)In-octreotide single-photon emission computed tomography. The results of treatment were compared with a historical control group of ONSM patients who were either observed or treated surgically and then observed.

RESULTS:
Our study population comprised 18 women and 12 men with a median age of 44 years (age range, 20-76 yr). The median isosurface radiation dose was 51 Gy (dose range, 50-54.0 Gy), and the median clinical follow-up time was 89 weeks (range, 9-284 wk). Of 22 optic nerves with vision before CF-SRT, 20 nerves (92%) demonstrated preserved vision, and 42% manifested improvement in visual acuity and/or visual field at follow-up. Comparison of our patients with a historical control group revealed preserved vision in only 16% of patients in a comparable period of observation, along with a 150% greater probability of visual improvement. Four patients (13%) had posttreatment morbidities, including visual loss (two patients), optic neuritis (one patient), and transient orbital pain (one patient). On magnetic resonance imaging studies, there was no evidence of tumor progression or recurrence in all patients, including tumor volume reductions noted in four patients. All six patients monitored with (111)In-octreotide scintigraphy demonstrated significant decreases in tumor activity after CF-SRT.

CONCLUSION:
To date, this article describes the largest reported series of ONSMs. Although longer follow-up is necessary, we think that CF-SRT represents a safe alternative to surgery and offers a higher likelihood of preserved or improved vision in patients with ONSM. Our analysis suggests that CF-SRT is also preferable to observation. Functional (111)In-octreotide single-photon emission computed tomographic scintigraphy provides a useful technique for the assessment of tumor control that complements serial posttreatment magnetic resonance imaging in patients with ONSMs

[Ulrich]

http://virtualtrials.com/news3.cfm?item=1668

Is stereotactic radiotherapy adequate treatment for atypical and malignant meningiomas?

Simon S Lo, Kwan H Cho, Walter A Hall, Wilson L Hernandez, Kimberly K McCollow, Judy Unger, University of Minnesota, Minneapolis, MN.

Objective: To evaluate whether stereotactic radiotherapy alone is an adequate treatment for recurrent atypical and malignant meningiomas.

Method: From 1992 to 2000, 10 patients with 16 recurrent atypical (A) or malignant (M) meningiomas (5 A and 11 M) were treated with stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT). Patients with tumors greater than 4 cm or closer than 5 mm to the optic apparatus were chosen for FSRT. The SRS doses ranged from 1200 cGy at 50% to 4500 cGy at 50% and the FSRT doses ranged from 4500 cGy at 85% in 25 fractions to 5000 cGy at 90% in 20 fractions. A 2 mm margin was placed around the target as defined on the computerized tomography. The median follow-up ranged from 3 months to 66 months. Five patients had external beam radiation therapy to the same areas previously. All patients had radiologic follow-up with magnetic resonance imaging.

Result: The 5-year actuarial tumor control was 31%. Five (50%) of the 10 patients developed recurrence. Two (40%) of the five patients who developed recurrence had disease recurring in the area outside the treated areas with no evidence of local recurrence. The time to recurrence ranged from 3 to 66 months. Three patients recurred after more than 3 years. The crude tumor shrinkage rate was 19%. The crude local progression rate was 31%.
Result: Our analysis showed that stereotactic therapy alone for the treatment of atypical and malignant was associated with poor tumor control. The suboptimal local control and the propensity of A and M for regional recurrence warrant the investigation of more aggressive and innovative therapies. The potential long latency for tumor recurrence underscores the importance of long-term follow-up of these patients.

[henri]

Hallo Ulrich

Ich habe die Beträge zu diesem Thema mit Interesse gelesen. Wir haben sehr überlegt, ob wir eine solche Radiotheraphie bei dem Rezidiv von 3,5 cm machen lassen sollten. Wir waren auch in der Uniklinik einer deutschen Großstadt in NRW, wo man bereit war, einen solchen Eingriff durchzuführen, nicht mit dem Gamma-Knife sondern mit dem X-Knife.

Unser Verwandter (Arzt) hat uns aber davon abgeraten, weil der Tumor mit 3,5 cm Durchmesser schon zu gross sei. Es würde zuviel gesundes Hirngewebe beschädigt (maximale Grösse sei 3,0 cm, wurde uns inzwischen auch von anderer Stelle bestätigt).

Gruß

Henri

[Nachsatz von Ulrich: Vgl. dazu Henris Beiträge unter: http://www.mc600.de/forum/index.php?board=39;action=display;threadid=498]

[Ulrich]

Henri,

ich sehe bei diesem Durchmesser auch noch ein ganz anderes Problem. Nehmen wir an, die Zellen werden bestrahlt, zerfallen, das Material muß ja irgendwie "aufgenommen" und "verarbeitet" werden. Wenn Zellwände zerfallen, kommt viel niedermolekulares Material "zu Tage". Der osmotische Druck muß steigen. Es wird zu Flüssigkeitseinlagerungen kommen, der Hirndruck steigt, es kommt zu Schwellungen, Ödem. (So stelle ich mir das als "gebildeter Nichtmediziner" jedenfalls vor). Hoher Hirndruck würde mir riesige Sorgen machen. Dann lieber Operation (falls einigermaßen zugänglich).

Gruß

Ulrich

[Ulrich]

Hier noch einige weitere Artikel zur Strahlentherapie von Meningeomen, z.T. auch von malignen Meningeomen:

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Int J Radiat Oncol Biol Phys 1990 Apr;18(4):755-61

The role of radiotherapy in the management of intracranial meningiomas: the Royal Marsden Hospital experience with 186 patients.

The 10-year actuarial cause-specific survival was 67% for all cases and the actuarial disease-free survival was 61%. Of those who underwent subtotal or partial tumor resection with post-operative radiotherapy the 10-year actuarial cause-specific survival was 77%, and in inoperable patients treated by radiotherapy alone it was 46%. Radiotherapy alone resulted in improvement of neurological performance (Karnofsky) in 12 out of the 32 (38%) patients with inoperable disease. The 10-year survival of patients referred for irradiation following "complete" surgical resection was only 34% owing to the high incidence of adverse histological sub-types in this treatment sub-group. Patients undergoing complete surgical resection for the typical benign non-aggressive meningioma do not require adjuvant irradiation. The results of this study support the role of radiotherapy for treatment of incompletely resected and inoperable meningioma of all 3 histological types (benign, "aggressive benign", malignant).


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Int J Radiat Oncol Biol Phys 1988 Aug;15(2):299-304

The meningioma controversy: postoperative radiation therapy.

The actuarial local control rates at 10 years for the three treatment groups were as follows: subtotal excision alone, 18%; subtotal excision plus postoperative radiation therapy, 82%; and total excision alone, 77%. The actuarial determinate survival rates at 10 years were 49%, 81%, and 93%, respectively. Postoperative radiation therapy was also effective for patients treated at the time of the first recurrence, with an actuarial local control rate at 10 years after salvage treatment of 30% for patients treated with surgery alone and 89% for patients receiving postoperative radiation therapy at the time of salvage. This analysis suggests that radiation therapy has a significant role in the treatment of subtotally excised and recurrent intracranial meningiomas.


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J Neurosurg 1994 Feb;80(2):195-201

Postoperative irradiation for subtotally resected meningiomas. A retrospective analysis of 140 patients treated from 1967 to 1990.

Retrospectively analyzed 140 patients treated at the University of California, San Francisco, from 1967 to 1990 to evaluate the results of radiation therapy (median 5400 cGy) given as an adjuvant to subtotal resection of intracranial meningioma. Of the 140 meningiomas, 117 were benign and 23 were malignant. The overall survival rate at 5 years was 85% for the benign and 58% for the malignant tumor groups ; the 5-year progression-free survival rates were 89% and 48%, respectively. For patients with benign meningioma, the 10-year overall and progression-free survival rates were 77%. The 5-year progression-free survival rate for patients with benign meningioma treated after 1980 (when computerized tomography or magnetic resonance imaging was used for planning therapy) was 98%, as compared with 77%for patients treated before 1980. Morbidity (3.6%) included sudden blindness or cerebral necrosis and death. When total resection of benign meningioma is not feasible, subtotal resection combined with precise treatment planning techniques and adjuvant radiation therapy can achieve results comparable to those of total resection.

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J Neurooncol 1992 Jun;13(2):157-64

The role of radiotherapy in the treatment of subtotally resected benign meningiomas.

Progression-free survival for 17 patients irradiated after initial incomplete surgery was 88% at 8 years compared with 48% for similar patients treated by surgery alone . 16 patients incompletely resected at time of first recurrence were irradiated and 78% were progression-free at 8 years while 11% of a similar group treated by surgery alone were progression free (p = 0.001). Long term overall survival was high and similar in both control and study groups. Two patients were irradiated at second recurrence and 1 patient at third recurrence. Twenty-five patients were treated with photons alone and have a median follow-up of 57 months, 6 patients have recurred at doses 45-60 Gy. Eleven patients were treated with combined 10 MV photons and 160 MV protons utilizing 3-D treatment planning. These patients have been followed for a median of 53 months and none have failed to date. Eight of 11 received 54-60.4 Gy and 3/11 greater than 64.48 Gy.


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Neurosurgery 1987 Apr;20(4):525-8

Radiation therapy in the treatment of partially resected meningiomas.

We reviewed the records of all patients admitted to the University of California, San Francisco, between 1968 and 1978 who had a diagnosis of intracranial meningioma. The patients were divided into three groups: 51 patients had gross total resection and did not receive radiation therapy, 30 patients had subtotal resection and no radiation therapy, and 54 patients had subtotal resection followed by radiation therapy. The subtotal resection groups were similar in average age, male:female ratio, and tumor location, which allowed a valid comparison of the effects of irradiation. The recurrence rate in the total resection group was 4% (2 of 51 patients). Among patients in the subtotal resection groups, 60% of nonirradiated patients had a recurrence, compared with only 32% of the irradiated patients. The median time to recurrence was significantly longer in the irradiated group than in the nonirradiated group (125 vs. 66 months, P less than 0.05). There was no complication related to irradiation. These results provide convincing evidence that radiation therapy is beneficial in the treatment of partially resected meningiomas.
 

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Mayo Clin Proc 1998 Oct;73(10):936-42

Primarily resected meningiomas: outcome and prognostic factors in 581 Mayo Clinic patients, 1978 through 1988.

From 1978 through 1988, 581 patients underwent initial resection of a previously untreated primary meningioma at Mayo Clinic Rochester. Gross total resection (GTR) of the meningioma was accomplished in 80% of patients; the other 20% underwent less than GTR. Progression-free survival at 5 and 10 years was 88% and 75%, respectively, in patients who underwent GTR and 61% and 39%, respectively, in those who underwent less than GTR. A trend toward improved progression-free survival was noted after first recurrence when irradiation with or without operation was used in comparison with only surgical treatment [P = 0.058 ]. CONCLUSION: With only operative treatment of meningioma, the 10-year recurrence rate was 25% in patients who had GTR and 61% in those who had less than GTR. These results emphasize the need for long-term follow-up and for consideration of adjuvant radiation therapy. Patients treated at the time of recurrence seem to benefit from radiation therapy with or without surgical resection.


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J Neurosurg 1985 Jan;62(1):18-24

Meningioma: analysis of recurrence and progression following neurosurgical resection.

The rates of survival, tumor recurrence, and tumor progression were analyzed in 225 patients with meningioma who underwent surgery as the only treatment modality between 1962 and 1980. The absolute 5-, 10-, and 15-year survival rates were 83%, 77%, and 69%, respectively. Following a total resection, the recurrence-free rate at 5, 10, and 15 years was 93%, 80%, and 68%, respectively, at all sites. In contrast, after a subtotal resection, the progression-free rate was only 63%, 45%, and 9% during the same period (p less than 0.0001). The probability of having a second operation following a total excision after 5, 10, and 15 years was 6%, 15%, and 20%, whereas after a subtotal excision the probability was 25%, 44%, and 84%, respectively (p less than 0.0001). Tumor sites associated with a high percentage of total excisions had a low recurrence/progression rate. For example, 96% of convexity meningiomas were removed in toto, and the recurrence/progression rate at 5 years was only 3%. Parasellar meningiomas, with a 57% total excision rate, had a 5-year probability of recurrence/progression of 19%. Only 28% of sphenoid ridge meningiomas a second resection, the probability of a third operation at 5 and 10 years was 42% and 56%, respectively.


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Int J Radiat Oncol Biol Phys 1996 Mar 1;34(4):817-22

Radiotherapy for atypical or malignant intracranial meningioma.

The records of the 59 patients who were treated at the Princess Margaret Hospital between 1966 and 1990 with histologically confirmed intracranial atypical or malignant meningiomas were retrospectively reviewed. The median age was 58 years. Twenty-four patients were referred for radiation immediately after diagnosis and the remainder after at least one recurrence. All patients received megavoltage radiation to a median dose of 50 Gy.
RESULTS: Disease progressed in 39 patients (66%) after radiation. The 5-year actuarial overall and cause-specific survivals were 28 and 34%, respectively. Age less than 58, treatment after 1975, and a radiation dose of 50 Gy or more were independently associated with higher cause-specific survival by multivariate analysis. CONCLUSIONS: Young age, modern imaging and treatment planning techniques, and a postoperative radiation dose of at least 50 Gy contribute to improved outcome in patients with atypical or malignant meningiomas. We recommend that all patients receive radiotherapy immediately after initial surgery.


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J Neurooncol 1998 Apr;37(2):177-88

Malignant meningioma: an indication for initial aggressive surgery and adjuvant radiotherapy.

Thirty-eight patients were treated with 48 malignant meningioma resections performed (28 total and 20 subtotal), 25 at initial presentation and 23 for recurrent disease; 19 patients received postoperative radiotherapy.  Actuarial disease free/progression free survival (DFS) at 5 years was 39% following total resection versus 0% after subtotal resection. For all totally excised lesions, the 5-yr DFS was improved from 28% for surgery alone to 57% with adjuvant radiotherapy. Adjuvant irradiation following initial resection increased the 5-yr DFS rates from 15% to 80%. When administered for recurrent lesions, adjuvant radiotherapy improved the 2-yr DFS from 50% to 89%, but had no impact on 5-yr DFS. Malignant meningiomas display a tendency for post surgical recurrence, with recurrence significantly increased for multicentric and recurrent disease. Complete surgical resection and the administration of adjuvant irradiation following initial resection are crucial to long-term control.

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J Neurosurg 1996 May;84(5):733-6

Adjuvant combined modality therapy for malignant meningiomas.

Malignant meningiomas constitute 10% to 15% of all meningiomas and limited information exists regarding adjuvant treatment of these aggressive primary brain tumors. Fourteen patients (eight men, six women), ranging in age from 28 to 61 years (median 51 years), were prospectively treated for primary malignant meningiomas according to an institutional protocol. All patients underwent surgery (gross-total in four and subtotal resection in 10 patients) followed in 2 to 4 weeks by involved-field radiotherapy (range 59-60 Gy, median dose 60 Gy). Two to 4 weeks after radiotherapy all patients were treated with adjuvant chemotherapy that included cyclophosphamide, adriamycin, and vincristine (CAV). Patients who underwent gross-total resection received three cycles, whereas those with subtotal resection received six cycles of CAV. The median time to tumor progression was 4.6 years (range 2.2-7.1 years) and median survival was 5.3 years (range 2.6-7.6 years). The author concludes that combined modality therapy for the treatment of malignant meningiomas is associated with acceptable toxicity and a modest improvement in survival when compared to patients treated with surgery alone.

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Neurosurgery 1998 Mar;42(3):446-53; discussion 453-4

Results of linear accelerator-based radiosurgery for intracranial meningiomas.

We reviewed 127 patients with 155 meningiomas treated with stereotactic radiosurgery (SRS) at the study institutions between October 1988 and December 1995.The median tumor volume was 4.1 cc (range, 0.16-51.2 cc), and the median marginal dose was 15 Gy (range, 9-20 Gy). Freedom from progression was observed in 107 patients (84.3%) at a median time of 22.9 months (range, 1.2-79.8 mo). Twenty patients (15.7%) had disease progression (16 marginal [12.6%] and 4 local [3.1%]) at a median time of 19.6 months (range, 4.1-69.3 mo); the median time for freedom from progression for the benign, atypical, and malignant meningiomas was 20.9, 24.4, and 13.9 months, respectively. Actuarial tumor control for the patients with benign meningiomas was 89.3% at 5 years. Six patients (4.7%) had permanent complications attributable to SRS  13 patients died as a result of causes related to the meningiomas (median, 17.5 mo; range, 4.3-37.3 mo). The 5-year survival probability for the entire group of patients was  68.2%,  for patients with benign meningiomas, excluding death resulting from intercurrent disease, the survival probability was 91.0%, . The 4-year survival probability for the patients with atypical and malignant meningiomas was 83.3% and21.5%, respectively. CONCLUSION: Even though complications from SRS are expected more frequently with large tumors near critical structures, SRS is a safe and effective means of treating selected meningiomas.

[Ulrich]

Technol Cancer Res Treat. 2005 Dec;4(6):675-82.    

Intensity-modulated radiation therapy (IMRT) for newly diagnosed and recurrent intracranial meningiomas: preliminary results.

Sajja R, Barnett GH, Lee SY, Harnisch G, Stevens GH, Lee J, Suh JH.

Department of Radiation Oncology, Brain Tumor Institute, Cleveland Clinic Foundation, OH 44195, USA. suhj@ccf.org

The purpose of this study was to evaluate tumor control, complications, and outcome from intensity-modulated radiation therapy (IMRT) for intracranial meningiomas. Between July 1997 and November 2003, patients with intracranial meningiomas were treated at our institution with the NOMOS Peacock system utilizing the Multileaf Intensity Modulating Collimator (MIMiC). Thirty-five patients with 37 lesions (35 benign and two atypical histology) were identified with a minimum of six months of radiologic follow-up for this retrospective review. The median age of the patients was 65 years with a median KPS of 90 prior to treatment with IMRT. The median MRI/CT follow-up for the 37 treated lesions was 19.1 months (range 6.4-62.4 months). Twenty meningiomas (54%) were previously treated with surgery/radiosurgery prior to IMRT, and 17 meningiomas (46%) were treated with IMRT primarily after diagnosis was established by MRI/CT. The median time from previous surgery to treatment with IMRT was 18.1 months. The median tumor dose was 50.4 Gy prescribed to the 87% isodose line providing a median target coverage of 95%. Local control was at 97% three years after treatment with IMRT. Only three patients exhibited local failure after treatment. Although local control was slightly better in the upfront-IMRT lesions as compared to the lesions treated with prior surgery/radiosurgery (100% vs 95%), this difference was not statistically significant. On univariate analysis, the IMRT prescription dose and maximum dose were found to be predictors for local control (p=0.05). On multivariate analysis, these factors did not remain significant for influencing local control. No long-term complications from IMRT were documented among the 35 patients. In conclusion, intensity-modulated radiation therapy is a safe and effective treatment for some intracranial meningiomas. A greater number of patients with longer follow-up after treatment may be needed to determine treatment variables predicting for long-term tumor control.

[Ulrich]

J Neurol Neurosurg Psychiatry. 2005 Oct;76(10):1425-30.    

Long term experience of gamma knife radiosurgery for benign skull base meningiomas.

Kreil W, Luggin J, Fuchs I, Weigl V, Eustacchio S, Papaefthymiou G.

Department of Neurosurgery, Medical University Graz, Graz, Austria. wolfgang.kreil@meduni-graz.at

OBJECTIVES: As most reports on the gamma knife have related only to short or mid-term results, we decided to evaluate the effectiveness and toxicity of radiosurgical treatment for benign skull base meningiomas in 200 patients with a follow up of 5-12 years to define the role of gamma knife radiosurgery (GKRS) for basal meningiomas and to provide further data for comparison with other treatment options.

METHODS: In total, 99 patients were treated with a combination of microsurgical resection and GKRS. In 101 patients, GKRS was performed as the sole treatment option. Tumour volumes ranged from 0.38 to 89.8 cm3 (median 6.5 cm3), and doses of 7-25 Gy (median 12 Gy) were given to the tumour borders at covering isodose volume curves (range 20-80%, median 45%).

RESULTS: The actuarial progression free survival rate was 98.5% at 5 years and 97.2% at 10 years. Passing radiation induced oedema occurred in two patients (1%). The neurological status improved in 83 cases (41.5%), remained unaltered in 108 (54%), and deteriorated in 9 (4.5%). Worsening was transient in seven patients (3.5%) and unrelated to tumour or treatment in one (0.5%). Repeated microsurgical resection was performed in five patients following GKRS (2.5%).

CONCLUSIONS: GKRS has proved to be an effective alternative to microsurgical resection, radiotherapy, and Linac based radiosurgery for adjunctive and primary treatment of selected patients with basal meningiomas. Because of the excellent long term tumour control rate and low morbidity associated with GKRS, this treatment option should be used more frequently in the therapeutic management of benign skull base meningiomas.

[Ulrich]

Br J Neurosurg. 2005 Feb;19(1):13-20.    

The use of stereotactic radiosurgery in the management of meningiomas.

Malik I, Rowe JG, Walton L, Radatz MW, Kemeny AA.

National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK.

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.