Radiosurgery/Stereotactic Radiotherapy in the Therapeutical Concept for Skull Base Meningiomas

Abstract

Objective: Microsurgical resection is still the treatment of choice for skull base meningiomas. But the risk of postoperative neurological deficits is high, and in many of these cases complete tumor removal cannot be achieved. Therefore recurrences are even more probable. Stereotactically guided radiation therapy - radiosurgery (RS) or stereotactic radiotherapy (SRT) - offers an additional or alternate treatment option for those patients. We evaluated local control rates, symptomatology, and toxicity.

Patients and Methods: 224 patients were treated with stereotactically guided radiation techniques in two departments between 1997 and 2003. 129 of 224 had recurrences after 1 to 3 prior tumor resections and 95 of 224 were treated with SRT/RS alone. 87.9% of cases had benign, 7.8% had atypical and 4.3% had malignant meningiomas. RS was only applied in 11 cases. Tumor volumes ranged from 0.16 ccm to 3.56 ccm. The other 213 patients had larger tumor volumes of up to 135 ccm or a meningioma close to optical structures. Therefore 183 cases were treated with SRT in normal fractions of 1.8-2 Gy in single doses up to 60 Gy. Hypofractionated SRT with single fraction doses of 5 or 4 Gy was applied in 30 cases. Follow-up data were available in 181 skull base meningiomas and the progression-free and overall survival rates, the toxicity and symptomatology were evaluated.

Results: The median follow-up was 36 months. The overall survival and the progression-free survival rates for 5 years were 92.9%, and 96.9%, respectively. Two tumor progressions have occurred to date but further follow up is required. Tumor volumes (TV) had shrunk about by 19.7% at 6 months (p<0.0001) and by 23.2% at 12 months (p<0.01) after SRT/RS. In 95.6% the symptoms had improved or were stable. Clinically significant acute toxicity (grade III) was seen in only 1 case (2.7%). Some patients developed late toxicity: 8.8% had grade I, 4.4% had grade II and 1.1% had grade III. No other neurological deficits occurred during follow-up.

Conclusion: SRT and RS offer an additional or alternative treatment option with a high efficacy and few side effects for the tumor control of skull base meningiomas. An individual and interdisciplinary decision respecting treatment is needed for each patient. In cases of large TV (>4 ccm), tumors adjacent to critical structures (<2 mm) or in high-risk patients the use of SRT offers greater benefits.

Zusammenfassung

Einführung: Die mikrochirurgische Resektion ist immer noch die Therapie der Wahl bei Schädelbasis-Meningeomen. Aber das Risiko postoperativer neurologischer Ausfälle ist hoch. Deshalb kann eine komplette Tumorentfernung oft nicht erreicht werden und Rezidive sind häufiger. Radiochirurgie (RS) oder stereotaktische Radiotherapie (SRT) bieten für diese Patienten eine zusätzliche oder alternative Behandlungsoption. Wir untersuchten die Tumorkontrolle, die Symptomatik und die Komplikationen.

Patienten und Methode: 224 Patienten wurden zwischen 1997 und 2003 in zwei Abteilungen mit SRT oder RS behandelt. 129/224 hatten Rezidive nach 1-3 vorherigen Tumorresektionen und 95/224 keine Vorbehandlung. 87,9% waren benigne, 7,8% atypische und 4,3% maligne Meningeome. Die RS wurde nur bei 11 Fällen mit Tumorvolumina von 0,16-3,56 ccm durchgeführt. Die anderen 213 Patienten hatten ein größeres Tumorvolumen bis zu 135 ccm oder optische Strukturen waren involviert. Deshalb wurden 183 Patienten mit einer SRT in konventioneller Fraktionierung von 1,8-2 Gy Einzeldosen bis zu 60 Gy Gesamtdosis behandelt. Eine hypofraktionierte stereotaktisch geführte Radiatio (SRT) mit Einzeldosen von 5 oder 4 Gy wurde in 30 Fällen appliziert. Die Verlaufsdaten waren von 181 Patienten mit Schädelbasis-Meningeomen verfügbar; deren Tumorkontroll- und Überlebensraten, Toxizität und Symptomatik wurden evaluiert.

Ergebnisse: Die mediane Verlaufsbeobachtung betrug 36 Monate, die 5-Jahres-Überlebens- und Tumorkontrollraten waren 92,9% und 96,9%. Bis jetzt wurden 2 Tumorprogressionen beobachtet - längere Verlaufskontrollen sind natürlich erforderlich. Eine Tumorschrumpfung um 19,7% fand sich 6 Monate nach der SRT/RS (p<0,0001) und um 23,2% nach 12 Monaten (p<0,01). In 95,6% der Fälle verbesserten sich Symptome oder waren unverändert. Es traten klinisch relevante Akuttoxizität in 2,7% und Spätsymptome (Toxizität Grad I: 8,8%, II: 4,4% und III: 1,1%) auf, jedoch keine zusätzlichen neurologischen Ausfälle.

Schlussfolgerung: SRT und RS bieten eine additive oder alternative Behandlungsoption mit hoher Effizienz und wenig Nebenwirkungen für die Tumorkontrolle von Schädelbasis- Meningeomen. Für jeden Patient ist eine individuelle, interdisziplinäre Therapieentscheidung erforderlich. In Fällen mit größerem Tumorvolumen (>4 ccm), bei Beteiligung besonders strahlenempfindlicher Strukturen beziehungsweise bei Hochrisiko-Patienten sollte die SRT bevorzugt werden.

Key words

skull base meningioma - stereotactic radiotherapy - radiosurgery - follow-up

Schlüsselwörter

Schädelbasis-Meningeome - stereotaktische Radiotherapie - Radiochirurgie - Verlaufsbeobachtung

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