Stereotactic radiotherapy for treatment of cavernous sinus meningiomas

doi:10.1016/j.ijrobp.2003.09.003

International Journal of Radiation OncologyBiologyPhysics

Volume 59, Issue 1, 1 May 2004, Pages 101-111

Presented at the 85th Annual Meeting of the American Radium Society, Houston, TX, April 26, 2003.

https://doi.org/10.1016/j.ijrobp.2003.09.003 Get rights and content

Abstract

Purpose

To assess the safety and efficacy of stereotactic radiotherapy (SRT) using a linear accelerator equipped with a micromultileaf collimator for cavernous sinus meningiomas.

Methods and materials

Forty-five patients with benign cavernous sinus meningiomas were treated with SRT between November 1997 and April 2002. Sixteen patients received definitive treatment on the basis of imaging characteristics of the cavernous sinus tumor. Twenty-nine patients received SRT either as immediate adjuvant treatment after incomplete resection or at documented recurrence. Treatment planning in all patients included CT–MRI image fusion and beam shaping using a micromultileaf collimator. The primary tumor volume varied from 1.41 to 65.66 cm³ (median, 14.5 cm³). The tumor diameter varied from 1.4 to 7.4 cm (median, 3.8 cm). Tumor compressed the optic chiasm or optic nerve in 30 patients. All tumors were treated with a single isocenter plus a margin of normal parenchyma varying from 1 to 5 mm (median, 2.5 mm). The prescribed dose varied from 4250 to 5400 cGy (median, 5040 cGy). The prescription isodose varied from 87% to 95% (median, 90%). The maximal tumor dose varied from 5000 to 6000 cGy (median, 5600 cGy). The follow-up varied from 12 to 53 months (median, 36 months).

Results

The actuarial 3-year overall and progression-free survival rate was 100% and 97.4%, respectively. One patient (2%) developed local relapsed at 18 months. A partial imaging response occurred in 18% of patients, and the tumor was stable in the remaining 80%. Preexisting neurologic complaints improved in 20% of patients and were stable in the remainder. No patient, tumor, or treatment factors were found to be predictive of imaging or clinical response. Transient acute morbidities included headache responsive to nonnarcotic analgesics in 4 patients, fatigue in 3 patients, and retroorbital pain in 1 patient. No treatment-induced peritumoral edema, cranial neuropathy, endocrine dysfunction, cognitive decline, or second malignancy occurred. One patient had an ipsilateral cerebrovascular accident 6 months after SRT.

Conclusion

Stereotactic radiotherapy is both safe and effective for patients with cavernous sinus meningiomas. Field shaping using a micromultileaf collimator allows conformal and homogeneous radiation of cavernous sinus meningiomas that may not be amenable to single-fraction stereotactic radiosurgery because of tumor size or location. Additional clinical experience is necessary to determine the position of SRT among the available innovative fractionated RT options for challenging skull base meningiomas.

Introduction

Despite significant advances in neuroimaging and microsurgical techniques, meningiomas of the cavernous sinus continue to represent a neurosurgical challenge. The preoperative assessment demonstrates total encasement or narrowing of the intracavernous portion of the internal carotid artery in 63% of patients (1). Furthermore, although the microscopic appearance of meningioma is typically benign, careful histopathologic analysis has demonstrated infiltration of adjacent vascular structures and cranial nerves by cavernous sinus lesions 2, 3, 4. Consequently, the reported rates of gross total resection for cavernous sinus meningiomas vary from 12% to 84% 5, 6, 7, 8, 9. Local recurrence is reported in 9.6–25% of patients despite confirmed total resection of cavernous sinus meningioma on imaging 1, 6, 7, 9. Local progression is even more frequent after subtotal removal of meningioma. In a series of 119 cavernous sinus meningiomas, DeJesus et al.(1) reported a 5-year relapse-free survival rate of 81% after complete resection compared with 62% after incomplete tumor removal. Attempted removal of cavernous sinus meningiomas has been associated with serious morbidity. The rate of exacerbation or induction of cranial neuropathy resulting from cavernous sinus surgery varies from 6% to 18% 6, 9. In addition, hemorrhage and cerebrospinal fluid leak have been reported in 5% and 21%, respectively (1).

Conventional external beam radiotherapy (RT) has been demonstrated to be an effective adjunctive therapy after subtotal resection of intracranial meningioma and a useful primary treatment modality for unresectable or inoperable tumors (10). Several authors have demonstrated relapse-free survival rates after external beam RT for cavernous sinus meningiomas that equal or exceed the rates achieved by radical resection 11, 12. External beam RT, however, may occasionally produce long-term optic, pituitary, or cognitive dysfunction 13, 14, 15.

Stereotactic radiosurgery (SRS) is a method for delivering a large, single dose of radiation to an intracranial site (16). The inherently steep dose gradient produced by SRS affords physical protection of the normal tissue adjacent to the target lesion. SRS has proved effective for a variety of benign central nervous system disorders, including meningiomas (17). Local control rates of 86–100% have been reported after either γ-knife or linear accelerator-based SRS for selected patients with cavernous sinus meningiomas 18, 19, 20, 21, 22, 23, 24, 25, 26, 27.

Despite the dosimetric advantages of SRS, use of this technique for cavernous sinus meningiomas has resulted in a 1.5–10.5% serious morbidity rate, predominantly affecting the cranial nerves 18, 19, 21, 23, 24, 25, 26, 27. Morbidity after SRS is strongly associated with the tumor volume and location 28, 29. For these reasons, application of SRS to cavernous sinus meningiomas has generally been restricted to tumors <3 cm in greatest dimension and located several millimeters from the optic apparatus 25, 27, 29.

Stereotactic RT (SRT) combines the physical dose localization advantages of SRS with the radiobiologic benefits of dose fractionation (30). Unlike SRS, the treatment planning fiducial system and patient immobilization device can be applied noninvasively (31). The accuracy of patient repositioning during SRT has been documented 32, 33. A total fractionated dose of ionizing radiation, known from conventional RT experience to be effective for meningioma and tolerated by the central nervous system, can be delivered by the SRT technique. SRT has proved safe and efficacious for a variety of skull base tumors, including meningiomas (34). We report the results of SRT using a dedicated linear accelerator equipped with a micromultileaf collimator (MMLC) for 45 patients with meningiomas of the cavernous sinus. Most of the patients had tumors considered ineligible for treatment by SRS.

Section snippets

Methods and materials

Between November 1997 and April 2002, 53 patients with cavernous sinus meningiomas received SRT at the University of California, Los Angels, Center for the Health Sciences. Eight patients from other states or countries were not available for follow-up evaluation. The analysis was limited to the remaining 45 patients (35 women and 10 men). The median age was 59 years (range, 19–85 years). Sixteen patients presented for treatment with primary tumors. Twenty-nine underwent SRT either immediately

Results

The median follow-up for the patients in this series was 36 months (range, 12–53 months). Thirty-one patients were followed for at least 2 years. One patient (2%) had local tumor progression 18 months after SRT. This patient was 78 years old at the time of treatment and had undergone prior subtotal resection of a meningothelial meningioma. The tumor volume at SRT was 6.95 cm³. The tumor plus a 3-mm margin was treated with 180-cGy fractions prescribed at 90% to a total dose of 5040 cGy. After

Discussion

The 3-year actuarial local control rate of 97.4% in this series is similar to the results reported elsewhere after innovative fractionated approaches for cavernous sinus meningiomas (Table 1). Debus et al.(34) reported the only other results of SRT for meningiomas. In a series of 189 patients with skull base meningiomas, including 21 affecting the cavernous sinus, local relapse was reported in 3 of 180 Grade 1 tumors after a median follow-up of 35 months. In a series of 40 meningioma patients,

Conclusion

Preliminary experience has demonstrated that SRT is a safe and effective therapeutic option for patients with cavernous sinus meningiomas. SRT may be particularly effective for tumors that are not amenable to SRS owing to lesion size and/or proximity to the optic apparatus. Longer follow-up is required to determine whether the encouraging local control rate is maintained and whether the normal tissue sparing achieved by MMLC field shaping results in a reduction in delayed central nervous system

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Management of cavernous sinus meningiomas: Consensus statement on behalf of the EANS skull base section
2022, Brain and Spine
The evolution of cavernous sinus meningiomas (CSMs) might be unpredictable and the efficacy of their treatments is challenging due to their indolent evolution, variations and fluctuations of symptoms, heterogeneity of classifications and lack of randomized controlled trials. Here, a dedicated task force provides a consensus statement on the overall management of CSMs.
To determine the best overall management of CSMs, depending on their clinical presentation, size, and evolution as well as patient characteristics.
Using the PRISMA 2020 guidelines, we included literature from January 2000 to December 2020. A total of 400 abstracts and 77 titles were kept for full-paper screening.
The task force formulated 8 recommendations (Level C evidence). CSMs should be managed by a highly specialized multidisciplinary team. The initial evaluation of patients includes clinical, ophthalmological, endocrinological and radiological assessment. Treatment of CSM should involve experienced skull-base neurosurgeons or neuro-radiosurgeons, radiation oncologists, radiologists, ophthalmologists, and endocrinologists.
Radiosurgery is preferred as first-line treatment in small, enclosed, pauci-symptomatic lesions/in elderly patients, while large CSMs not amenable to resection or WHO grade II-III are candidates for radiotherapy. Microsurgery is an option in aggressive/rapidly progressing lesions in young patients presenting with oculomotor/visual/endocrinological impairment. Whenever surgery is offered, open cranial approaches are the current standard. There is limited experience reported about endoscopic endonasal approach for CSMs and the main indication is decompression of the cavernous sinus to improve symptoms. Whenever surgery is indicated, the current trend is to offer decompression followed by radiosurgery.
External beam radiation therapy for meningioma
2020, Handbook of Clinical Neurology
Citation Excerpt :
Nonvisual deficits are rare. Selch et al. looked at 45 cavernous sinus meningioma patients who received a total dose of 50.4 Gy at 1.7–1.8 Gy per fraction and found no patients with treatment-related cranial neuropathies (Selch et al., 2004). Urie et al. came up with similar conclusions in this dose range in the setting of proton radiotherapy (Urie et al., 1992).
Radiation therapy (RT) plays an important role in the management of meningioma. Surgery often remains the initial treatment of choice as it reduces mass effect and confirms the diagnosis and grade. However, RT has frequently been successful in the primary setting and is commonly employed as adjuvant therapy for incompletely resected tumors as well as for high-grade meningiomas regardless of resection extent. Some meningiomas develop in locations less amenable to resection or in patients who are poor surgical candidates, in which circumstances RT is particularly appropriate as primary treatment. Recent cooperative group studies including RTOG 0539 have better established the role of RT for meningioma. These studies suggest a role for adjuvant RT for completely resected Grade II meningioma, which was less clear historically. Ongoing clinical trials such as NRG BN 003 and ROAM will further clarify this. This chapter reviews the role of fractionated external beam RT for various grades of meningioma.
Skull base meningioma: Clinical and radiological efficacy based on a quantitative volumetric analysis
2019, Cancer/Radiotherapie
Recherche d’une corrélation entre efficacité clinique et radiologique basée sur un suivi volumétrique quantitatif après irradiation de méningiomes de la base du crâne.
Les données de 35 patients pris en charge, soit par tomothérapie hélicoïdale (45,7 %), soit par radiothérapie fractionnée en conditions stéréotaxiques (54,3 %), ont été rétrospectivement analysées. Il s’agissait principalement de femmes (94 %) de 59 ans (43–81) avec des lésions du sinus caverneux (60 %). Il y avait une médiane de 2 (1–4) symptômes par patient, principalement des troubles visuels (39 %), des déficits des nerfs crâniens (23,4 %) et les céphalées (17,2 %).
Le volume tumoral avait significativement diminué (p < 0,05) passant d’une médiane de 9,6 mL (0,3–36,6) à 6,8 mL (0,1–26,5) après un suivi médian de 44 mois (24–77). Une amélioration d’au moins un symptôme a été retrouvée chez 63 % des patients. En analyse unifactorielle, l’efficacité clinique (p < 0,05), la technique de radiothérapie (p < 0,05), la topographie tumorale (p < 0,05) et le volume tumoral initial (p < 0,05) étaient des facteurs prédictifs de la réponse radiologique. En analyse multifactorielle, seule la corrélation inverse entre réponse radiologique et volume tumoral initial demeurait significative (ρ : −0,47 ; intervalle de confiance à 95 % : −3,2–5,7 ; p < 0,05).
Le suivi volumétrique quantitatif permet de mettre en évidence une efficacité radiologique majeure de la radiothérapie. Cependant, aucune corrélation franche entre efficacité clinique et radiologique n’a été retrouvée.
To date, no correlation has been found between clinical and radiological efficacy after irradiation of skull base meningiomas. However, the evaluation of the radiological response was most often made by questionable methods that may have underestimated the radiological effectiveness of radiotherapy. The objective of this work is to verify this hypothesis by quantitative volumetric analysis.
Data from 35 patients treated with either helical tomotherapy (45.7%) or fractionated stereotactic radiotherapy (54.3%) were retrospectively analysed. These were mainly women (94%) aged 59 (43–81) with lesions mainly of the cavernous sinus (60%). There was a median of 2 (1–4) symptoms and the main symptoms were visual impairment (39%), cranial nerve deficits (23.4%) and headaches (17.2%).
Median tumour volume decreased significantly (P < 0.05) from 9.6 mL (0.3–36.6) to 6.8 mL (0.1–26.5) after median follow-up of 44 months (24–77). Sixty-three percent of patients had an improvement of at least one symptom. In univariate analysis, clinical efficacy (P < 0.05), radiotherapy technique (P < 0.05), tumor topography (P < 0.05) and initial tumor volume (P < 0.05) were predictive factors for radiological response. In multivariate analysis, only the inverse correlation between radiological response and initial tumor volume remained significant (ρ: −0.47 95% CI −3.2 to 5.7; P < 0.05).
The quantitative volumetric monitoring demonstrates a major radiological efficiency of radiotherapy. However, no clear correlation between clinical and radiological efficacy was found.
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2017, American Journal of Ophthalmology Case Reports
We report the case of a patient with cavernous sinus syndrome associated with biopsy-confirmed metastasis from colorectal cancer.
A patient known for laryngeal carcinoma and metastatic colorectal carcinoma presented with symptoms of left trigeminal neuralgia and progressive, near-complete ophthalmoplegia. Magnetic resonance imaging (MRI) revealed a mass in the left cavernous sinus, extending into Meckel's cave with perineural spread along the mandibular branch of the left trigeminal nerve. A transsphenoidal biopsy was performed and demonstrated metastatic colon adenocarcinoma. We review the existing literature on colorectal cancer associated cavernous sinus syndrome.
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Online databases were searched for studies published until April 2015. The primary outcomes were disease control and progression-free-survival(PFS). The secondary outcomes were symptom control and radiation-induced toxicity.
The estimate of disease control rate ranged from 87.0% to 100.0% at 5 years and from 67.0% to 100.0% at 10 years. The PFS rate ranged 78.0%–98.9% and 53.1%–97.2% at 5 and 10 years, respectively. The overall symptom control was 92.3%, the overall toxicity was 8.1%.
RS can be considered a safe and effective treatment. Efforts are needed in standardizing the definition of local and symptom control and toxicity in order to properly compare different treatment schedules.
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Clinical investigationStereotactic radiotherapy for treatment of cavernous sinus meningiomas

Abstract

Purpose

Methods and materials

Results

Conclusion

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Long-term follow-up of patients with meningiomas involving the cavernous sinusRecurrence, progression and quality of life

Neurosurgery

Infiltration of the carotid artery by cavernous sinus meningioma

J Neurosurg

Evidence of meningioma infiltration into cranial nervesClinical implications for cavernous sinus meningiomas

J Neurosurg

Meningiomas involving the cavernous sinusHistological factors affecting the degree of resection

J Neurosurg

Cavernous sinus meningiomas

Neurochirugia

Clinical investigation
Stereotactic radiotherapy for treatment of cavernous sinus meningiomas