Table 2.
Results of the main series of meningioma treated with photon radiation therapy.
| Author | Year of publication | N. pts | Technique | Dose and fractionation | Mean FU (months) | Outcome | Toxicity | Comments and authors conclusion |
|---|---|---|---|---|---|---|---|---|
| Aicholzer et al.22 | 2000 | 46 | Gamma knife | 9–25 Gy margin dose in single fraction | 48 | LC 96% | Minimal toxicity: 1 case (2%) of transient paresis, 1 case (2%) of hypopituitarism |
No difference in outcome in post operative vs. radical treatment |
| Zachenhofer et al.23 | 2006 | 36 | Gamma knife | 9–25 Gy margin dose in single fraction | 103 | LC 94% | 1 abducens nerve palsy, 1 focal seizure, 1 hypopituitarims (8% developed toxicity) |
Subset of Aicholzer's series with longer follow-up, confirms same findings |
| Metellus et al.24 | 2005 | 74 | 3D-CRT (38 patients) Gamma knife (36 patients) |
50–55 Gy (1.6–2 Gy/fr) for 3D-CRT; 6–25 Gy in single fraction prescription 30–70% isodose |
91 (median) for 3D-CRT (extrapolated from graph); 80 (median) for GK (extrapolated from graph) |
LC 97.4% for 3D-CRT; LC 94.4% for GK |
No significant toxicity in 3D-CRT group, 1 transient stroke in GK group |
Pts treated with GK had smaller tumours, there was no apparent difference in outcome between the two modalities |
| Kreil et al.25 | 2005 | 200 | Gamma knife | 7–25 Gy in single fraction prescription 20–80% isodose | 95 (median) | Actuarial 5y LC 98.5% 10y LC 97.2% |
1 pt (0.5%) with worsening cranial nerve symptoms | SRS may replace surgery in selected cases |
| Han et al.26 | 2008 | 63 | Gamma knife | 7–20 Gy margin dose in single fraction | 77 | LC 94% | 2 pts (2%) had recurrent seizures, 10 pts (16%) had worsening of cranial nerves symptoms |
SRT can be an alternative to surgery, toxicity is acceptable but not negligible |
| Igaki et al.27 | 2009 | 98 | Gamma knife | 14–18 Gy in single fraction prescription 40–50% isodose | 53 (median) | Actuarial 5y LC 87% 10y LC 79% |
4 pts (4%) with worsening of cranial nerve symptoms | Tumour volume smaller than 4 cc and complete target coverage were associated with better LC |
| Nakaya et al.28 | 2010 | 44 | Gamma knife | 13 Gy margin dose in single fraction | 60 (median) | LC 100% | 1 pt (worsening of neurological deficit) | SRT can be an alternative to surgery. All tumours caused brainstem compression |
| Pollock et al.29 | 2012 | 251 | Gamma knife | Mean margin dose 15.8 ± 2 Gy | 62.9 | 98.8% | Toxicity in 23 patients (9.2%): cranial nerves deficit 15 pts, headache 5 pts, hemiparesis 5 pts, seizure 4 pts, cyst formation 1 pts, stroke 1 pts | Long follow up is needed, local recurrence were observed after more than 10 years |
| Chuang et al.30 | 2004 | 43 | LINAC SRT | 7–25 Gy in single fraction prescription 80% isodose | 74.5 (median) | Actuarial 7y LC 89.7% |
2 pts (4.7%) with toxicity (actuarial 7y LC 89.7%) | No difference in outcome in post operative vs. radical treatment |
| Selch et al.31 | 2004 | 45 | LINAC SRT | 42.5–54 Gy (2 Gy/fr), 90% isodose |
36 (median) | 98% | 1 cerebrovascular event | All tumours were in the cavernous sinus |
| Correa et al.32 | 2014 | 89 | LINAC SRS (single fraction), or fSRT | fSRT: 45–50 Gy in (1.8–2 Gy/fr); SRS 13–15 Gy at 80–90% isodose |
73 (median) | Actuarial 5y, 10y and 15y DFS: 98.8%, 92.3%, 92.3% |
No sever toxicity, only transient events | All tumours were in the cavernous sinus, larger lesion and lesion close to optic pathways were treated with SRT. There was no difference in outcome between SRS and SRT |
| Kaul et al.33 | 2014 | 136 | LINAC fSRT | 32.4–63 Gy (1.8–2 Gy/fr) |
44.9 (median) | Actuarial 5y PFS: 93.8%, 10y PFS 91.5% |
37.5% of the patients showed grade I or II late fatigue or headache | Fractionated SRT is used for tumours close to OAR, there may be a relevant selection bias when comparing with SRS |
| Soldà et al.34 | 2013 | 145 | LINAC fSRT | 50–55 Gy (1.5–1.66 Gy/fr) |
43 (median) | Actuarial 5y LC 93% 10y LC 86% |
8 pts (3.5%) worsening vision, 1 pt (0.5%) trigeminal neuralgia, 2 pts (1%) cognitive impairment, 2 pts (1%) cerebrovascular accidents |
Selection bias may hinder retrospective series comparison with different techniques |
| Tanzler et al.35 | 2011 | 103 | 3D-CRTor IMRT or fSRT | 50.4–55.8 Gy (1.86 Gy/fr) |
88 (median) | Actuarial 5y LC 96% 10y LC 95% |
10 pts (7%) had significant toxicity: - 2 pts developed brain necrosis and 1 pt died of it, - 2 pts developed bilateral optic neuropathy and blindness, - 1 pt developed unilateral retinopathy an impaired vision - 1 pt developed cataract, - 1 pt developed hydrocephalus and necessitated a shunt, - 1 pt developed osteomyielitis of ear canal and required surgical debridement, - 1 pt died of steroid therapy complications |
All tumours where WHO grade I. There was no difference in outcome between post operative and definitive RT. Fractionated SRT is a treatment option for patients not candidate to radical surgery or SRS |
| Litré et al.36 | 2009 | 100 | LINAC fSRT | 45 Gy (1.8 Gy/fr) | 33 | Actuarial 7y LC 94% |
Toxicity in 23 patients(9.2%): cranial nerves deficit 15 pts, headache 5 pts, hemiparesis 5 pts, seizure 4 pts, cyst formation 1 pt, stroke 1 pt | All tumours where in the cavernous sinus, fractionated SRT is the first option for meningioma in the cavernous sinus |
| Hamm et al.37 | 2008 | 224 | LINAC fSRT/SRS | fSRT: 60 Gy (1.8–2 Gy/fr); SRS single fraction of 4–5 Gy |
36 (median) | Actuarial 5YPFS 96.9% | Late grade III toxicity 2.7% | Radiotherapy may be an alternative to surgery, for large tumours or tumours close to critical structures fractionated RT may be beneficial |
| Combs et al.38 | 2013 | 507 | IMRT/fSRT with LINAC or tomotherapy | 25–68 Gy (1.6–5 Gy/fr) |
107 (median) | Actuarial 5y LC 95% 10y LC 88% |
QOL was decreased due to disease or therapy only in 8 patients (3%). S | Atypical and anaplastic histologies had significantly worse outcome (10YLC 53%). Small lesions may be treated with SRS, lesion close to critical organ may benefit from fSRT, complex shape lesion may benefit from IMRT. The choice between wait and see, surgery or RT should be made in a multidisciplinary setting |
| Milker-Zabel et al.13 | 2007 | 94 | IMRT | 50.4–62 Gy (1.8 Gy/fr) |
53 (median) | 93.6% | 4.3% of the pts had worsening of neurological symptoms | IMRT can be useful in complex shaped tumours |
| Minniti et al.39 | 2011 | 52 | LINAC fSRT | 50 Gy (1.66 Gy/fr) | 42 (median) | Actuarial 5y LC 93% | 10 pts (19%) developed hypopituitarism, 1 pt had neurocognitive impairment and 1 pt had increase in seizure frequency | fSRT is an acceptable technique |
| Colombo et al.40 | 2009 | 199 | Cyberknife | 11–25 Gy in 3–5 fr at 70–90% isodose | 30 | 96.5% | Worsening cranial nerve deficit in 0.5% of the pts | Cyberknife allowed treatment of pts not candidate to SRS |
| Choi et al.41 | 2010 | 25 | Cyberknife | 16–30 Gy in 1–4 fr to 62–91% isodose | 28 (median) | Actuarial 3y LC 74% | 1 pt with brain necrosis, 1 pt with hydrocephalus |
All pts were WHO grade II, post op irradiation may be beneficial in these subset, SRT may be an alternative to surgery |
| Oermann et al.42 | 2013 | 38 | Cyberknife | 25– 35 Gy in 5 fraction | 20 (median) | 100% | Only transient toxicity | Fractionation may be beneficial for large lesions |
| Starke et al.43 | 2012 | 225 | Gamma knife | 8–30 Gy in single fraction at 28–80% isodose | 78 (median) | LC at last FU 86%; actuarial 5y LC 96% 10y LC 79% | 25 pts (10%) had worsening of neurological symptoms | SRS is useful for tumours in critical sites |
| Pourel et al.44 | 2001 | 28 skull base pts out of 45 meningioma | 3D-CRT | 50–70 Gy (1.8–2 Gy/fr) |
30 (median) | Actuarial 5yPFS 75%; 8y PFS 67%, results reported for the whole series (45 pts) | 1 case of hemiparesis, trigeminal neuralgia, and decline of cognitive function, | Series include exclusive RT, post op RT and salvage RT |
| Jalali et al.45 | 2002 | 41 | LINAC fSRT | 50–55 Gy in 30–33 fractions | 21 (median) | 100% | 2 cases of hypopituarism, 2 cases of worsening neurocognitive impairment, 1 case of worsening visual field deficit | fSRT is alternative to surgery for tumours difficult to resect |
| Torres et al.46 | 2003 | 128 | LINAC SRT or SRS | SRS 12–22.85 Gy peripheral dose, SRST 23.8–54 Gy in 5–30 fractions | 32.5 | 94.8% (SRS 92% SRT 97.2%) | 5 pts had worsening of pre-existing symptoms | Difference between SRS and SRT are likely due to bias in length of follow up and imaging quality, results were much worse (tumour control at last FU 38.1% in atypical tumours) |
| Henzel et al.47 | 2006 | 84 | LINAC fSRT | 50.4–60 Gy (1.8–2 Gy/fr) |
30 (median) | 100% | Not reported | Only WHO grade I, volume shrinkage depends on initial tumour volume and age, young (<56 years) patient with small tumours showed more tumour regression |
| Brell et al.48 | 2006 | 30 | LINAC fSRT | 50–56 Gy (2 Gy/fr) |
50 (median) | Actuarial 4YLPFS 93% | 1 pt with neuropsychological deficit and seizure, 1 pts with short term memory loss and dysphasia | All tumours in cavernous sinus |
| Kondziolka et al.49 | 2008 | 563 skull base pts out of 972 reported meningiomas | Gamma knife | 14 Gy mean peripheral dose | 48 (median) | WHO I 93% WHO II 50% WHO III 17% (both skull base and non skull base data) |
15-Year actuarial complication rates 9.1%: hydrocephalus 0.4%, cranial nerve deficit 3.4%, headaches 2.2%, seizures 2.4%, motor deficit 1.4%, sensory deficit 0.3% (non skull base pts included) | SRS can be used for recurrent meningioma or as first line treatment |
| Kollová et al.50 | 2007 | 368 | Gamma knife | 6.5–24 Gy margin dose in single fraction at isodose 40–90% | 60 (median) | Actuarial 5y LC 97.9% | Permanent morbidity in 5.7% of the patients | Marginal dose of less than 12–16 Gy is associated with worse local control |
| Hasegawa et al.51 | 2007 | 115 | Gamma knife | 7.5–17 Gy margin dose | 62 (median) | Actuarial 5y LC 94%; 10y LC 92% | 11 pts (12%) had worsening of pre-existing symptoms or developed new symptoms | SRS is alternative to surgery in cavernous sinus meningioma |
| Malik et al.52 | 2005 | 277 | Gamma knife | 10–30 Gy to the tumour margins | 44 | WHOI actuarial 5y LC 87%, 8y LC 75%; WHO II actuarial 5y LC 49%; WHO III actuarial 5y LC 0%, gross LC 28% |
1 case of worsening VII cranial nerve deficit, 3 cases of transient trigeminal pain, 3 cases of diplopia 2 cases of weakness (tumour close to motor cortex) |
Tumour grade was the strongest predictor of local control |
| Nicolato et al.53 | 2002 | 122 | Gamma knife | 11–22.5 Gy in single fraction at 30–65% isodose | 48.9 (median) | Actuarial 5y PFS 96.5% | 1 case of intracranial hypertension and worsening cranial nerve deficit | All tumours were in the cavernous sinus; SRS may be considered the first-choice treatment modality cavernous sinus meningioma |
| Roche et al.54 | 2000 | 92 | Gamma knife | 6–25 Gy at isodose of 30%-70% | 30.5 (median) | Actuarial 5y-PFS 92.8% | 1 case of worsening trigeminal neuralgia, 1 case of complex partial seizures and 1 case of transient carotid occlusion | Gamma knife can be alternative to surgery for meningioma of the cavernous sinus |
| Villavicencio et al.55 | 2001 | 56 | LINAC SRS | 9–18.5 Gy margin dose in single fraction | 26 (median) | 95% | 5 pts (9%) had permanent late toxicity: 1 difficulty in gait, 2 visual field deficit, 2 cerebral oedema | SRS is indicated both in adjuvant setting and as first line for poor surgical candidates |
| Friedman et al.56 | 2005 | 210 | LINAC SRS | 10–20 Gy in single fraction at 70–80% isodose | 24 (minimum) | Actuarial 5y LC WHO I 96%, WHO II 77% WHO III 19% | 5 pts (2.3%) permanent toxicity, all in WHO III tumours | LINAC SRS is an optimal treatment for WHO I meningiomas |
| Stafford et al.57 | 2001 | 147 skull base cases out of 190 meningiomas | Gamma knife | 12–36 Gy in single fraction at 50% isodose | 47 (median) | Actuarial 5y LC WHOI 93%, WHO II 68% WHO III 0% | 24 pts (13%) had permanent late toxicity: 15 cranial nerve deficit, 5 symptomatic MR detectable parenchyma change, 2 carotid stenosis, 2 cystic lesion | SRS can be used in the treatment of meningioma; grade II and III tumours have worse outcome |
LC = local control (LC as freedom form tumour progression at last FU); FU = follow up; pt/pts = patient/patients; GK = gamma knife; SRT = stereotactic radiotherapy; fSRT = fractionated SRS; SRS = radiosurgery; fr = fraction; PFS = progression free survival; OAR = organ at risk; DFS = disease free survival.