Gamma knife radiosurgery for Koos grade 4 vestibular schwannomas
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1 Gamma knife radiosurgery for Koos grade 4 vestibular schwannomas David Mathieu MD FRCSC, Christian Iorio-Morin MD PhD, Fahd Al Subaie MD MSc FRCSC Division of neurosurgery, Université de Sherbrooke, Centre Hospitalier Universitaire de Sherbrooke Sherbrooke, Qc, Canada 18th Leksell Gamma Knife Society Meeting, Amsterdam, Netherlands May 17th 2016
2 Disclosure No conflict of interest to disclose
3 Background Gamma knife radiosurgery (GKRS) is recognized as a first line management option for small to moderate-size vestibular schwannomas Tumor control rates 90-98% Low morbidity Management of larger size tumors remains a subject of debate Koos classification used to orient management
4 Koos classification Koos grade 4 tumors Koos et al, JNS, 1998
5 Objectives of the study Evaluate the efficacy and safety of GKRS for appropriately selected Koos grade 4 VS Tumor control Hearing evolution Facial preservation Radiation-induced complications
6 Inclusion criteria Patients treated in Sherbrooke between August 2004 and April 2014 Koos grade 4 tumors with volume more than 4 cc Minimum follow-up 6 months No NF2 No symptomatic intracranial hypertension or brainstem compression
7 Treatment protocol MR sequences: contrast-enhanced MPRAGE and CISS-3D Tumor: usual margin dose of 12 Gy to treatment isodose Brainstem: limit 12-Gy volume to < 1 cc Cochlea: aim for mean dose < 4 Gy Semi-circular canals: no dose constraint Trigeminal nerve: no dose constraint
8 Patient workflow
9 Volumetric analysis Performed using itk- SNAP software version on a dedicated station
10 Patient population Median age at radiosurgery (range) 58 (16-85) Male:Female ratio 1.4:1 Preceding surgical intervention Resection 13 (19%) VP shunt insertion 5 (7%) Baseline hearing and facial function Gardner-Robertson grade (hearing function) I 16 (24%) II 24 (35%) III 15 (22%) IV 2 (3%) V 11 (16%) House-Brackmann scale (facial function) I 62 (91%) II 0 (0%) III 1 (1.5%) IV 0 (0%) V 1 (1.5%) VI 4 (6%) Median follow-up 47 months (6-125)
11 Tumor characteristics Indication for GKRS Primary treatment 55 (81%) Adjuvant treatment for residual tumor following surgery 8 (12%) Recurrence following gross total resection 5 (7%) Radiological tumor characteristics at time of GKRS Median volume in cc (range) 7.4 (4-19) Median max CPA diameter in cm (range) 2.7 (2-4) Cystic component 13 (19%) Median cyst size in cm 3 (range) 2 (1-4.2)
12 Dosimetry Median marginal dose (range) 12 Gy (11-13) Median isodose line used (range) 50% (50-55) Median cochlear radiation dose (range) Median semi-circular canals dose (range) Median brainstem radiation dose (range) Median trigeminal nerve radiation dose (range) Gardner-Robertson grade I & II Mean dose: 4.3 Gy ( ) Maximal dose: 6.8 Gy ( ) Gardner-Robertson grade III, IV & V Mean dose: 5.1 Gy ( ) Maximal dose: 7.6 Gy ( ) Mean dose: 3.7 Gy (2.7-7) Maximal dose: 7.5 Gy ( ) Mean dose: 3.3 Gy ( ) Maximal dose: 11.9 Gy ( ) Mean dose: 7.2 Gy ( ) Maximal dose: 11.7 Gy ( )
13 Tumor control Crude local control 94% (4 failures) Actuarial control: 2 years: 95% 10 years: 92% Transient volume increase in 41% At median of 8 months (6-13 mo) Increased risk of failure (univariate only) higher tumor volume Lower dose
14
15 1 year 2 years 3 years 5 years
16 Hearing preservation Actuarial hearing preservation: 85% at 2 years, 49% at 5 years No significant factor for hearing preservation
17 Evolution of initial symptoms Number of patients verigo tinnitus facial pain dysequilibrium facial numbness improved stabalized worsened Persistence of symptoms associated with larger tumors initially 5.9 cc vs 9.8 cc (p=0.003)
18 Complications Most were mild: steroids required in 3.7% of patients Tend to occur at the time of transient tumor increase No factor was found predictive of occurrence No worsening of motor facial function No radiation-induced neoplasia VP shunt required in 3 patients for symptomatic hydrocephalus
19 10 Evolution of common post treatment adverse events 9 8 number of patients treated persisted resolved facial pain dysequilibrium facial numbness tinnitus
20 Conclusions Koos grade 4 tumors are not all the same! GKRS can be a safe and effective option for Koos grade 4 VS Clinical presentation of patients should be the predominant factor in decision-making for these patients, if volume is deemed appropriate
21
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