Stereotactic radiosurgery in the treatment of parasellar meningiomas: long-term volumetric evaluation
Stereotactic radiosurgery in the treatment of parasellar meningiomas: long-term volumetric evaluation
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DOI：
10.3171/2016.11.jns161402
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发表时间：
2018-02-01
影响因子：
4.1
通讯作者：
Sheehan, Jason P.
中科院分区：
文献类型：
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作者：
Cohen-Inbar, Or;Tata, Athreya;Sheehan, Jason P.
目的鞍旁脑膜瘤常侵犯鞍上、海绵窦和岩斜区，侵犯邻近的神经血管结构。因此，它们被证明是难以安全和完全切除的。立体定向放射外科（SRS）在鞍旁脑膜瘤的治疗中起着核心作用。使用简化的单维测量来评估该部位的肿瘤控制率可能会产生误导。作者报告了SRS治疗参数以及SRS后良性WHO I级鞍旁脑膜瘤的时间和体积变化对长期预后的影响。方法选择WHO一级鞍旁脑膜瘤患者，接受单次SRS治疗，随访至少6个月。该队列共189例患者（22.2%为男性，n = 42）。患者年龄中位数为54岁（范围19-88岁）。44.4% （n = 84）的患者将SRS作为主要的前期治疗。大多数（41.8%,n = 79）患者在SRS术前接受了1次手术切除。SRS时中位肿瘤体积为5.6 cm(3) （0.2 ~ 54.8 cm(3)）。中位边缘剂量为14 Gy（范围5-35 Gy）。在后续扫描中确定鞍旁脑膜瘤的体积，通过使用梯形规则对脑膜瘤进行逐片分割和数值积分来计算。结果中位随访时间为71个月（6-298个月）。91.5% （n = 173）的患者肿瘤体积得到控制。肿瘤进展发生率为8.5% (n = 16)，野区复发发生率为4.2% (n = 8)，野区外复发发生率为4.2% （n = 8）。srs后，54例患者出现新的或加重的神经网络缺损，其中19例涉及三叉神经功能障碍，18例涉及视神经功能障碍。其中，90.7% （n = 49）是由于肿瘤进展，只有9.3% （n = 5）是由于SRS。总的来说，这意味着2.64% （n = 5/189）的srs直接相关并发症发生率。这些患者接受了重复SRS （6.3%, n = 12）、重复切除（2.1%,n = 4）或两者兼而有之（3.2%,n = 6）。对于边际剂量= 16 Gy的患者，2年、4年、6年、8年、10年、12年和15年精算无进展生存率分别为100%、100%、95.7%、95.7%、95.7%、95.7%、95.7%和95.7%。接受边际剂量>= 16 Gy治疗的患者，2年、4年、6年、8年、10年、12年和15年精算无进展生存率分别为99.4%、97.7%、95.1%、88.1%、82.1%、79.4%和79.4%。这种差异被认为具有统计学意义（p = 0.043）。回顾患者特异性体积测量，早期随访体积测量（随访3年）可靠地预测长期体积变化和肿瘤体积控制（随访10年）（p = 0.029）。结论SRS是一种持久的微创治疗良性鞍旁脑膜瘤的方法。与该地区脑膜瘤的其他治疗方式相比，SRS提供了高生长控制率和低神经功能障碍发生率。在SRS后3年的短期随访中，体积回归或稳定性被证明是预测长期肿瘤控制的指标。
OBJECTIVE Parasellar meningiomas tend to invade the suprasellar, cavernous sinus, and petroclival regions, encroaching on adjacent neurovascular structures. As such, they prove difficult to safely and completely resect. Stereotactic radiosurgery (SRS) has played a central role in the treatment of parasellar meningiomas. Evaluation of tumor control rates at this location using simplified single-dimension measurements may prove misleading. The authors report the influence of SRS treatment parameters and the timing and volumetric changes of benign WHO Grade I parasellar meningiomas after SRS on long-term outcome.METHODS Patients with WHO Grade I parasellar meningiomas treated with single-session SRS and a minimum of 6 months of follow-up were selected. A total of 189 patients (22.2% males, n = 42) form the cohort. The median patient age was 54 years (range 19-88 years). SRS was performed as a primary upfront treatment for 44.4% (n = 84) of patients. Most (41.8%, n = 79) patients had undergone 1 resection prior to SRS. The median tumor volume at the time of SRS was 5.6 cm(3) (0.2-54.8 cm(3)). The median margin dose was 14 Gy (range 5-35 Gy). The volumes of the parasellar meningioma were determined on follow-up scans, computed by segmenting the meningioma on a slice-by-slice basis with numerical integration using the trapezoidal rule.RESULTS The median follow-up was 71 months (range 6-298 months). Tumor volume control was achieved in 91.5% (n = 173). Tumor progression was documented in 8.5% (n = 16), equally divided among infield recurrences (4.2%, n = 8) and out-of-field recurrences (4.2%, n = 8). Post-SRS, new or worsening CN deficits were observed in 54 instances, of which 19 involved trigeminal nerve dysfunction and were 18 related to optic nerve dysfunction. Of these, 90.7% (n = 49) were due to tumor progression and only 9.3% (n = 5) were attributable to SRS. Overall, this translates to a 2.64% (n = 5/189) incidence of direct SRS-related complications. These patients were treated with repeat SRS (6.3%, n = 12), repeat resection (2.1%, n = 4), or both (3.2%, n = 6). For patients treated with a margin dose = 16 Gy, the 2-, 4-, 6-, 8-, 10-, 12-, and 15-year actuarial progression-free survival rates are 100%, 100%, 95.7%, 95.7%, 95.7%, 95.7%, and 95.7%, respectively. Patients treated with a margin dose >= 16 Gy, had 2-, 4-, 6-, 8-, 10-, 12-, and 15-year actuarial progression-free survival rates of 99.4%, 97.7%, 95.1%, 88.1%, 82.1%, 79.4%, and 79.4%, respectively. This difference was deemed statistically significant (p = 0.043). Reviewing the volumetric patient-specific measurements, the early follow-up volumetric measurements (at the 3-year follow-up) reliably predicted long-term volume changes and tumor volume control (at the 10-year follow-up) (p = 0.029).CONCLUSIONS SRS is a durable and minimally invasive treatment modality for benign parasellar meningiomas. SRS offers high rates of growth control with a low incidence of neurological deficits compared with other treatment modalities for meningiomas in this region. Volumetric regression or stability during short-term follow-up of 3 years after SRS was shown to be predictive of long-term tumor control.