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Radiosurgery and fractionated radiotherapy for cavernous sinus meningioma: a systematic review and meta-analysis

  • Review Article - Tumor - Meningioma
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Abstract

Introduction

Radiosurgery (RS) and fractionated radiotherapy (FRT) are part of the therapeutic armamentarium for the management of cavernous sinus meningiomas. We propose a systematic review of the local tumor control and clinical outcomes after monofractionated radiosurgical treatment, including gamma knife radiosurgery (GKRS) and linear accelerator (Linac RS), or fractionated radiotherapy.

Materials and Methods

The current review and meta-analysis adhered to the PRISMA guidelines. We performed a search in PubMed, Embase, and Medline based on the following mesh terms, used alone or in diverse combinations, in both title and abstract: “cavernous sinus,” “meningioma,” “radiosurgery,” “gamma knife,” “linac,” “cyberknife,” and “radiotherapy”. We screened 425 studies. We selected 36 studies, matching all selection criteria: 24 for GK, 5 for Linac, and 7 for FRT.

Results

Were included 2817 patients (GKRS, n = 2047, LinacRS, n = 350, FRT, n = 420). Half of patients benefited from upfront RS or FRT; the other half benefited from adjuvant RS or FRT (combined approach or tumor recurrence). The mean gross target volume (GTV) was smaller for RS as compared to FRT (p = 0.07). The median marginal doses were 13.9 Gy (range, 11 to 28) for GKRS and 14 Gy (range, 12.8 to 17.7) for LinacRS. For FRT, patients received a mean dose of 51.2 Gy (25.5 fractions, 1.85 Gy each). The mean overall follow-up values were 48 months (range, 15 to 89) for GKRS, 69 months (range, 46 to 87) for Linac, and 59.5 months (range, 33 to 83) for FRT. PFS at 5 years for GKRS, LinacRS, and FRT were respectively 93.6%, 95.6%, and 97.4% (p = 0.32, the Kruskal-Wallis). Monofractionated treatments (GKRS and LinacRS) induced more tumor volume regression than FRT (p = 0.001). Tumor recurrence or progression ranged between 3 and 5.8%, without statistically significant differences between modalities (p > 0.05). Trigeminal symptoms improved in approximately 54%, and III-IV-VI cranial nerves (CN) palsies improved in approximately 45%. After GKRS, visual acuity improved in 21% (not enough data available for other modalities). De novo deficits occurred in 5 to 7.5%. Adverse radiation effects appeared in 4.6 to 9.3% (all techniques pooled).

Conclusion

RS achieved a twice-higher rate of tumor volume regression than FRT. GKRS series reported an improvement in visual acuity in 21% of the cases. GKRS, Linac, and FRT provided similar clinical post therapeutic outcomes for the trigeminal and oculomotor CN.

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Authors and Affiliations

  1. Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

    Henri-Arthur Leroy, Constantin Tuleasca & Marc Levivier

  2. Department of Neurosurgery and Neuro-oncology, CHU Lille, F-59000, Lille, France

    Henri-Arthur Leroy & Nicolas Reyns

  3. Department of Neurosurgery, Lille University Hospital, Rue Emile Laine, 59037, Lille Cedex, France

    Henri-Arthur Leroy

  4. Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland

    Constantin Tuleasca & Marc Levivier

  5. Signal Processing Laboratory (LTS-5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland

    Constantin Tuleasca

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Comments

The authors should be commended for the large scale literature review of this challenging pathology. As one would expect, they found the literature varied in terms of the quality and quantity of provided material useful for such meta-analysis. They found that, Gamma Knife technology was used for smaller tumours, fractionated radiotherapy for large lesions and linear accelerator radiosurgery for those in between. Of note, CyberKnife publications did not meet their, in my view fair, criteria. It was also of note that fractionated radiotherapy publications included a wide range of protocols,e.g. the number of fractions ranged between 15 and 30, while the radiosurgery treatments were more similar to each other. Nevertheless, as the authors point out in Discussion, technology is constantly improving. This makes a retrospective review of often retrospective publications that require long follow-up for outcome to be demonstrated always less pertinent for current practice.

In terms of radiological outcome, they noted a significantly larger proportion of tumour shrinkage after gamma knife treatment than in the other groups, while local progression free survival did not significantly differ between the groups. Clinically, the outcomes appeared similar, with functional improvement whichever technology was used, although probably owing to the superior conformity and gradient index of gamma knife treatments there was more improvement of visual acuity when using GK. The authors found scarcity of data in this respect after linear accelerator radiosurgery compared with the more extensively detailed gamma knife publications. Published adverse radiation effects were also similar between the three modalities.

This paper, therefore, supports the perception prevalent amongst clinicians these days. Radiation therapy for cavernous sinus meningiomas is a well-tolerated and successful treatment and it seems to achieve better progression free survival than surgery alone. For smaller lesions, even those with visual impairment, gamma knife treatment is worthwhile and clinical improvement as well as tumour shrinkage is the norm. It is noteworthy that the vast majority of patients, three-quarters in these publications, were treated by gamma knife. The practice, if one goes by publications summarised here, is that larger tumours are treated with fractionated radiotherapy although visual improvement is less expected and in terms of adverse reactions it is not "safer". One will have to await publications upon results of using newer approaches, e.g. volume staging or even fractionation of larger tumours using the latest model of the gamma knife.

Andras Kemeny

Sheffiled, UK

This article is part of the Topical Collection on Tumor - Meningioma

Appendix 1

Appendix 1

Table 3 Description of all reviewed studies for each treatment modality, including hypofractionated treatment series
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Leroy, HA., Tuleasca, C., Reyns, N. et al. Radiosurgery and fractionated radiotherapy for cavernous sinus meningioma: a systematic review and meta-analysis. Acta Neurochir 160, 2367–2378 (2018). https://doi.org/10.1007/s00701-018-3711-9

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