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Linac-stereotactic Radiosurgery (LSRS) in the Management of Trigeminal Neuralgia: An Update of 51 Cases
I. J. Radiation Oncology d Biology d Physics
S238
Volume 72, Number 1, Supplement, 2008
median interval to diagnosis of radiation change from RT completion was 7 months (range, 1.1 to 168.8 months). Median hospital stay post-surgery was 4 days (range, 2 to 15 days). Overall survival was calculated from diagnosis of radiation change/necrosis to death. The 6, 12, and 24 month survival rates were 76%, 49%, and 27%, respectively. On univariate analysis, variables significantly associated with overall survival were increasing age (p = 0.0034, RR = 1.034, 95% CI, 1.011-1.058), poor tumor histological type (glioblastoma multiforme {GBM} p = 0.0058, RR = 5.664, 95% CI, = 1.66-19.33; metastatic disease p = 0.014, RR = 4.942, 95% CI, = 1.382-17.669) and absence of chemotherapy (p = 0.045, RR 0.550, 95% CI, = 0.307-0.987). On multivariate analysis, age (p = 0.0018, RR = 1.040, 95% CI, = 1.015-1.067) and tumor histology (GBM p = 0.0025, RR = 6.681, 95% CI, = 1.954-22.838; metastatic disease p = 0.0070, RR = 5.784, 95% CI, = 1.615-20.713; glioma p = 0.0223, RR = 4.101, 95% CI, = 1.222-13.761) were significant. Radiation changes/necrosis alone did not predict for survival. Conclusions: In this series, prognostic factors related to radiation change/necrosis are defined. Radiation change/necrosis only versus tumor recurrence did not predict for survival. The diagnosis of radiation necrosis continues to be a dilemma. Prospective evaluation is warranted. Author Disclosure: C.R. Peterson, None; J. Suh, None; L. Angelov, None; C. Reddy, None; S. Chao, Schering Plough, D. Speakers Bureau/Honoraria.
2153
Analysis of Recurrence and Survival Patterns in High Grade Glioma Treated with External Beam (3DCRT) and Stereotactic Radiotherapy (SRT) Combined with Concurrent Temozolomide and Carboplatin
C. Garran Del Rio, J. Aristu, M. Moreno, A. Gomez-Iturriaga, M. Pagola, R. Ciervide, J. Espinos, O. Fernandez, R. Diez-Valle, M. Manrique Clinica Universitaria De Navarra, Pamplona Navarra, Spain Purpose/Objective(s): The standard of care for patients (pts) with high-grade glioma with surgery followed by adjuvant temozolomide-based chemo-radiotherapy offers high recurrence and low survival rates. The objective is to evaluate efficiency, toxicity, and recurrence patterns in patients with high-grade glioma treated with concurrent temozolomide and weekly carboplatin-based chemotherapy and high-dose radiation. Materials/Methods: Radiation was initially delivered with 3D-CRT to the initial PTV1, defined as the GTV (T1 weighted MRI scan) with a margin of 2 cm, to a total dose of 50 Gy in 25 daily treatments. This was followed by a cone-down boost to the PTV2 (GTV + 0.7 cm) delivered with SRT to reach a boost of 20 Gy. Concurrent chemotherapy consisted of temozolomide (50 mg/m2 p.o., 5 days per week) and carboplatin (AUC = 1.5 once a week). Toxicity was evaluated using the RTOG criteria. Patterns of failure was classified in local (within PTV1), marginal (adjacent to PTV1) and distal (farthest to PTV1). Results: Between November 2000 and April 2006, 50 pts (median age 57 years) were included. The type of resection was biopsyonly in 40%, subtotal 44%, and total 16%. Twenty-five percent had anaplastic astrocytoma (AA) and 72% glioblastoma (GB). Distribution according to RPA class: I-III 34%, IV-VI 66%. Chemoradiotherapy compliance 66%. Toxicity: hematologic Grade 3-4, 22%. Severe late toxicity was observed in 1 pt (radionecrosis). Patterns of recurrence: local 24%, marginal 4%, distal 8%, and mixed 28%. With a median follow-up of 30 months (range, 3-77), the 2-year disease-free survival and overall survival were 16% and 39%, respectively. Median survival according to RPA class and histology: RPA I-III/RPA IV-VI: not achieved/15 months (p = 0.015); AA/GB: 25 months/19 months (p = ns). Conclusions: External beam radiotherapy 70 Gy with concurrent temozolomide/carboplatin is feasible. Some patients achieve long-term survival in spite of a high rate of unfavorable prognostic class. There has been a similar tolerance to other studies using conventional doses of radiotherapy and temozolomide as well as a low rate of local recurrence (52%). Author Disclosure: C. Garran Del Rio, None; J. Aristu, None; M. Moreno, None; A. Gomez-Iturriaga, None; M. Pagola, None; R. Ciervide, None; J. Espinos, None; O. Fernandez, None; R. Diez-Valle, None; M. Manrique, None.
2154
Linac-stereotactic Radiosurgery (LSRS) in the Management of Trigeminal Neuralgia: An Update of 51 Cases
S. Gurley1, R. Mark1,2, P. Anderson1, T. Neumann1, M. Nair1, R. Akins1, D. White1 1
Joe Arrington Cancer Center, Lubbock, TX, 2Texas Tech University, Lubbock, TX
Purpose/Objective(s): Stereotactic radiosurgery (SRS) with the gamma knife (GK) has been used successfully in the treatment of trigeminal neuralgia (TN). Results have been comparable to open surgery. There have been few reports with the use of LSRS in the management of TN. We report our updated results with LSRS in the treatment of TN. Materials/Methods: Between 2000 and 2008, 51 patients with medically refractory TN were treated with LSRS. Prior neurosurgical intervention had been performed in 39 patients. Twenty-two patients had one procedure, 14 patients had two, and 5 patients had three interventions. All patients had typical TN. An LSRS was given to the cranial nerve V entry root zone into the brainstem. Targeting was defined by CT and MRI scans, and CT cisternogram, utilizing axial and coronal images. Treatment planning was accomplished thru Radionics Treatment Planning System. The dose was 87 Gy to Dm, in one fraction using the 5 mm collimator and 6 arcs with the 20% isodose line just touching the brainstem. This dosimetry is similar to gamma knife. The dose rate was 400 MU/min. Average Arc length was 130 degrees. Response to treatment was defined as excellent (no pain, off analgesics), good (no pain, with analgesics), and poor (continued pain despite analgesics). Results: With a median follow-up of 58 months (range, 12-98 months), 68.6% (35/51) of patients have reported an excellent or good result after LSRS. One patient has sustained permanent ipsilateral facial numbness. Conclusions: Using LSRS offers comparable results to GK SRS in the management of TN. Author Disclosure: S. Gurley, None; R. Mark, None; P. Anderson, None; T. Neumann, None; M. Nair, None; R. Akins, None; D. White, None.
S238
Volume 72, Number 1, Supplement, 2008
median interval to diagnosis of radiation change from RT completion was 7 months (range, 1.1 to 168.8 months). Median hospital stay post-surgery was 4 days (range, 2 to 15 days). Overall survival was calculated from diagnosis of radiation change/necrosis to death. The 6, 12, and 24 month survival rates were 76%, 49%, and 27%, respectively. On univariate analysis, variables significantly associated with overall survival were increasing age (p = 0.0034, RR = 1.034, 95% CI, 1.011-1.058), poor tumor histological type (glioblastoma multiforme {GBM} p = 0.0058, RR = 5.664, 95% CI, = 1.66-19.33; metastatic disease p = 0.014, RR = 4.942, 95% CI, = 1.382-17.669) and absence of chemotherapy (p = 0.045, RR 0.550, 95% CI, = 0.307-0.987). On multivariate analysis, age (p = 0.0018, RR = 1.040, 95% CI, = 1.015-1.067) and tumor histology (GBM p = 0.0025, RR = 6.681, 95% CI, = 1.954-22.838; metastatic disease p = 0.0070, RR = 5.784, 95% CI, = 1.615-20.713; glioma p = 0.0223, RR = 4.101, 95% CI, = 1.222-13.761) were significant. Radiation changes/necrosis alone did not predict for survival. Conclusions: In this series, prognostic factors related to radiation change/necrosis are defined. Radiation change/necrosis only versus tumor recurrence did not predict for survival. The diagnosis of radiation necrosis continues to be a dilemma. Prospective evaluation is warranted. Author Disclosure: C.R. Peterson, None; J. Suh, None; L. Angelov, None; C. Reddy, None; S. Chao, Schering Plough, D. Speakers Bureau/Honoraria.
2153
Analysis of Recurrence and Survival Patterns in High Grade Glioma Treated with External Beam (3DCRT) and Stereotactic Radiotherapy (SRT) Combined with Concurrent Temozolomide and Carboplatin
C. Garran Del Rio, J. Aristu, M. Moreno, A. Gomez-Iturriaga, M. Pagola, R. Ciervide, J. Espinos, O. Fernandez, R. Diez-Valle, M. Manrique Clinica Universitaria De Navarra, Pamplona Navarra, Spain Purpose/Objective(s): The standard of care for patients (pts) with high-grade glioma with surgery followed by adjuvant temozolomide-based chemo-radiotherapy offers high recurrence and low survival rates. The objective is to evaluate efficiency, toxicity, and recurrence patterns in patients with high-grade glioma treated with concurrent temozolomide and weekly carboplatin-based chemotherapy and high-dose radiation. Materials/Methods: Radiation was initially delivered with 3D-CRT to the initial PTV1, defined as the GTV (T1 weighted MRI scan) with a margin of 2 cm, to a total dose of 50 Gy in 25 daily treatments. This was followed by a cone-down boost to the PTV2 (GTV + 0.7 cm) delivered with SRT to reach a boost of 20 Gy. Concurrent chemotherapy consisted of temozolomide (50 mg/m2 p.o., 5 days per week) and carboplatin (AUC = 1.5 once a week). Toxicity was evaluated using the RTOG criteria. Patterns of failure was classified in local (within PTV1), marginal (adjacent to PTV1) and distal (farthest to PTV1). Results: Between November 2000 and April 2006, 50 pts (median age 57 years) were included. The type of resection was biopsyonly in 40%, subtotal 44%, and total 16%. Twenty-five percent had anaplastic astrocytoma (AA) and 72% glioblastoma (GB). Distribution according to RPA class: I-III 34%, IV-VI 66%. Chemoradiotherapy compliance 66%. Toxicity: hematologic Grade 3-4, 22%. Severe late toxicity was observed in 1 pt (radionecrosis). Patterns of recurrence: local 24%, marginal 4%, distal 8%, and mixed 28%. With a median follow-up of 30 months (range, 3-77), the 2-year disease-free survival and overall survival were 16% and 39%, respectively. Median survival according to RPA class and histology: RPA I-III/RPA IV-VI: not achieved/15 months (p = 0.015); AA/GB: 25 months/19 months (p = ns). Conclusions: External beam radiotherapy 70 Gy with concurrent temozolomide/carboplatin is feasible. Some patients achieve long-term survival in spite of a high rate of unfavorable prognostic class. There has been a similar tolerance to other studies using conventional doses of radiotherapy and temozolomide as well as a low rate of local recurrence (52%). Author Disclosure: C. Garran Del Rio, None; J. Aristu, None; M. Moreno, None; A. Gomez-Iturriaga, None; M. Pagola, None; R. Ciervide, None; J. Espinos, None; O. Fernandez, None; R. Diez-Valle, None; M. Manrique, None.
2154
Linac-stereotactic Radiosurgery (LSRS) in the Management of Trigeminal Neuralgia: An Update of 51 Cases
S. Gurley1, R. Mark1,2, P. Anderson1, T. Neumann1, M. Nair1, R. Akins1, D. White1 1
Joe Arrington Cancer Center, Lubbock, TX, 2Texas Tech University, Lubbock, TX
Purpose/Objective(s): Stereotactic radiosurgery (SRS) with the gamma knife (GK) has been used successfully in the treatment of trigeminal neuralgia (TN). Results have been comparable to open surgery. There have been few reports with the use of LSRS in the management of TN. We report our updated results with LSRS in the treatment of TN. Materials/Methods: Between 2000 and 2008, 51 patients with medically refractory TN were treated with LSRS. Prior neurosurgical intervention had been performed in 39 patients. Twenty-two patients had one procedure, 14 patients had two, and 5 patients had three interventions. All patients had typical TN. An LSRS was given to the cranial nerve V entry root zone into the brainstem. Targeting was defined by CT and MRI scans, and CT cisternogram, utilizing axial and coronal images. Treatment planning was accomplished thru Radionics Treatment Planning System. The dose was 87 Gy to Dm, in one fraction using the 5 mm collimator and 6 arcs with the 20% isodose line just touching the brainstem. This dosimetry is similar to gamma knife. The dose rate was 400 MU/min. Average Arc length was 130 degrees. Response to treatment was defined as excellent (no pain, off analgesics), good (no pain, with analgesics), and poor (continued pain despite analgesics). Results: With a median follow-up of 58 months (range, 12-98 months), 68.6% (35/51) of patients have reported an excellent or good result after LSRS. One patient has sustained permanent ipsilateral facial numbness. Conclusions: Using LSRS offers comparable results to GK SRS in the management of TN. Author Disclosure: S. Gurley, None; R. Mark, None; P. Anderson, None; T. Neumann, None; M. Nair, None; R. Akins, None; D. White, None.