- Email: [email protected]
Meningiomas: A Retrospective Outcomes Analysis of a Single Institution Experience
International Journal of Radiation Oncology Biology Physics
S262
2151
brainstem (necrosis/infarction), and chiasm (blindness) for each fractionation. RTOG 0539 (schedule 1) was used as baseline standard of care fractionation (BSOCF) for comparison of toxicity, and an a/b ratio of 3.76 was used for all plans. WCMC institutional HSRT dose schedule was calculated using an a/b ratio of 3.76 to deliver an equivalent BED to that of the BSOCF. Results: The Table lists median NTCP risks of toxicities to the NBT, brainstem, and chiasm. There was no significant risk of toxicity to the brainstem or chiasm for any fractionation schedule compared to BSOCF (p > 0.33). Compared to BSOCF there was a significant decrease risk of toxicity to the NBT for schedule 3 (p Z 0.012), while schedules 2 (p Z 0.054) and 4 (p Z 0.19) were not significant. Conclusions: This analysis demonstrates that the HSRT schedule is not only a more convenient option which decreases OTT, but also that it rendered no significant toxicities to the brainstem, chiasm, or brain. These findings lay the foundation for further exploration in a clinical trial. Author Disclosure: M. Yondorf: None. L. Zhou: None. S. Wang: None. J. Chang: None. A. Sabbas: None. B. Parashar: None. D. Nori: None. K. Chao: None. S. Pannullo: None. A. Wernicke: None.
Meningiomas: A Retrospective Outcomes Analysis of a Single Institution Experience E.D. Tanzler, C.G. Morris, J.M. Kirwan, W.M. Mendenhall, and R.S. Malyapa; University of Florida Proton Therapy Institute, Jacksonville, FL Purpose/Objective(s): Meningiomas are a common primary intracranial brain tumor. We analyzed the local control and complications in patients with either pathologically or clinical World Health Organization Grade I meningiomas treated with definitive or postoperative proton therapy (PT) at a single institution. Materials/Methods: Between February 2007 and September 2011, 27 patients were treated with definitive 3-dimensional conformal PT (n Z 18) or postoperative PT after subtotal resection (n Z 9). Nineteen patients were treated for de novo presentation and 8 patients were treated for a recurrence after surgery. All patients were treated with proton therapy PT alone to a median dose of 50.4 Gy and followed for a median of 3.1 years (range, 0.3 to 5.9 years). Complications were graded using the Common Terminology Criteria for Adverse Events v4.0. Results: The 5-year local control, cause-specific survival, and overall survival rates were 89%, 94%, and 78%. Three patients experienced a recurrence. Of these, 1 patient died of the disease, 1 died of intercurrent disease, and 1 is living with the recurrence. Only 1 (3.7%) patient experienced a severe radiation therapy (RT) complication; this patient developed radiation necrosis 15 months after PT for multiple intracranial meningiomas. There were no severe surgical complications in the 9 patients treated with surgery and postoperative PT. Conclusions: The likelihood of cure after definitive PT or following subtotal resection is favorable. Nevertheless, as with photon radiation therapy outcomes, some patients experienced severe complications, even at the moderate dose used for this disease. This data suggest that proton therapy is a safe and effective treatment option for patients with meningiomas; however, further follow-up is necessary. Author Disclosure: E.D. Tanzler: None. C.G. Morris: None. J.M. Kirwan: None. W.M. Mendenhall: None. R.S. Malyapa: None.
2153 Impact of Radiation Therapy on Clinical Outcome of Meningiomas N.T. Nguyen,1 Y. Wang,1 L.L. Lyon,2 and J.L. Villano3; 1The Permanente Medical Group, Rancho Cordova, CA, 2Kaiser Permanente Division of Research, Oakland, CA, 3University of KY, Lexington, KY Purpose/Objective(s): Although meningioma is the most common primary brain tumor in the US, there is lack of standard guidelines in management due to limited data on clinical outcomes. Radiation therapy (RT) is used as treatment in <10% cases from population-based retrospective series. Materials/Methods: We performed descriptive and survival analyses of meningioma cases diagnosed 2001-2010 from the Kaiser Permanente Northern California Cancer Registry. Chart review extracted additional information on mortality, histology, imaging, tumor size, tumor site, treatment, and RT planning. Kaplan-Meier method was used to calculate overall survival (OS) and disease-free survival (DFS) and log-rank test to compare survival rates by variables. Cox proportional hazard models were used to analyze variables relative to endpoints. Results: One thousand nine hundred sixty-eight cases in 1792 patients with diagnosis of meningioma were analyzed. 55% of cases had histological confirmation. The 5- and 10-year OS and DFS for all groups were 76% and 61%, and 89% and 82%, respectively. Disease progression and recurrence presented in 10% of cases at 10 years, resulting in 4% diseasespecific mortality (DSM). Statistically significant prognostic factors of worse DFS were age 80, WHO grade 2-3, tumor size 18 mm, peritumoral edema (TE) on imaging, Simpson grades (SG) 4 or 5 and no surgery. Factors associated with significantly worse OS were age 60, male gender, tumor size 42 mm, TE, SG 4 or 5, no histology and no treatment (NT). SG 1-3 groups provided statistically the highest OS and DFS. There was no significant difference in DFS or OS for definitive RT vs surgery and adjuvant RT groups. Definitive RT showed significantly better OS than NT (HR Z 0.46; 95% CI, 0.21-0.98). Cases with progression or recurrence had 51% DSM with 65% of deaths associated with lack of salvage therapy. Salvage RT provided higher OS benefit compared to other salvage groups (HR Z 0.35; 95% CI, 0.14-0.91). 209 cases in 163 patients treated with RT were further analyzed. Modalities, using stereotactic radiosurgery (SRS), intensity modulated radiation therapy (IMRT), and 3-D conformal radiation therapy (CRT) for definitive, adjuvant or salvage therapy were
2152 NTCP Modeling of Hypofractionated Stereotactic Radiation Therapy (HSRT) for Patients With Subtotal Resection (STR) of WHO Grade 1 Meningioma: A Toxicity-Sparing More Convenient Treatment Method M. Yondorf, L. Zhou, S. Wang, J. Chang, A. Sabbas, B. Parashar, D. Nori, K. Chao, S. Pannullo, and A. Wernicke; Weill Cornell Medical College, New York, NY Purpose/Objective(s): HSRT for STR WHO grade I meningioma presents a more convenient treatment option for patients due to decreased overall treatment time (OTT). We use NTCP modeling to predict radiation toxicities in this patient population in HSRT as compared to standard fractionation schedule. Materials/Methods: Ten patients who underwent STR for newly diagnosed WHO grade I meningioma were retrospectively identified. Four plans for each patient (40 total plans) were created to compare the risk of toxicity based on the NTCP values. The fractionation of each plan is displayed in Table. GTV is defined as tumor cavity including residual disease. CTV and PTV were created by expanding GTV and CTV by 5mm, respectively. NTCP values were computed using standard models and toxicities calculated for normal brain tissue (NBT) (necrosis/infarction), Poster Viewing Abstract 2152; Table
Fractionation schedules and associated NTCP median risk of toxicity NTCP median risk of toxicity
1 2 3 4
Source for fractionation
Dose (Gy)
Fraction(s)
Total dose (Gy)
BED (Gy)
Brainstem
Chiasm
NBT
P value for NBT
RTOG 0539 Halasz, L 2011 Mahadevan, A 2011 WCMC Institutional HSRT Protocol
1.8 13 5 8
30 1 5 3
54 13 25 24
79.85 57.95 75.06 58.24
0.00% 0.00% 0.00% 0.00%
0.00% 0.00% 0.00% 0.00%
0.13% 0.01% 0.00% 0.25%
.054 .012 .19
S262
2151
brainstem (necrosis/infarction), and chiasm (blindness) for each fractionation. RTOG 0539 (schedule 1) was used as baseline standard of care fractionation (BSOCF) for comparison of toxicity, and an a/b ratio of 3.76 was used for all plans. WCMC institutional HSRT dose schedule was calculated using an a/b ratio of 3.76 to deliver an equivalent BED to that of the BSOCF. Results: The Table lists median NTCP risks of toxicities to the NBT, brainstem, and chiasm. There was no significant risk of toxicity to the brainstem or chiasm for any fractionation schedule compared to BSOCF (p > 0.33). Compared to BSOCF there was a significant decrease risk of toxicity to the NBT for schedule 3 (p Z 0.012), while schedules 2 (p Z 0.054) and 4 (p Z 0.19) were not significant. Conclusions: This analysis demonstrates that the HSRT schedule is not only a more convenient option which decreases OTT, but also that it rendered no significant toxicities to the brainstem, chiasm, or brain. These findings lay the foundation for further exploration in a clinical trial. Author Disclosure: M. Yondorf: None. L. Zhou: None. S. Wang: None. J. Chang: None. A. Sabbas: None. B. Parashar: None. D. Nori: None. K. Chao: None. S. Pannullo: None. A. Wernicke: None.
Meningiomas: A Retrospective Outcomes Analysis of a Single Institution Experience E.D. Tanzler, C.G. Morris, J.M. Kirwan, W.M. Mendenhall, and R.S. Malyapa; University of Florida Proton Therapy Institute, Jacksonville, FL Purpose/Objective(s): Meningiomas are a common primary intracranial brain tumor. We analyzed the local control and complications in patients with either pathologically or clinical World Health Organization Grade I meningiomas treated with definitive or postoperative proton therapy (PT) at a single institution. Materials/Methods: Between February 2007 and September 2011, 27 patients were treated with definitive 3-dimensional conformal PT (n Z 18) or postoperative PT after subtotal resection (n Z 9). Nineteen patients were treated for de novo presentation and 8 patients were treated for a recurrence after surgery. All patients were treated with proton therapy PT alone to a median dose of 50.4 Gy and followed for a median of 3.1 years (range, 0.3 to 5.9 years). Complications were graded using the Common Terminology Criteria for Adverse Events v4.0. Results: The 5-year local control, cause-specific survival, and overall survival rates were 89%, 94%, and 78%. Three patients experienced a recurrence. Of these, 1 patient died of the disease, 1 died of intercurrent disease, and 1 is living with the recurrence. Only 1 (3.7%) patient experienced a severe radiation therapy (RT) complication; this patient developed radiation necrosis 15 months after PT for multiple intracranial meningiomas. There were no severe surgical complications in the 9 patients treated with surgery and postoperative PT. Conclusions: The likelihood of cure after definitive PT or following subtotal resection is favorable. Nevertheless, as with photon radiation therapy outcomes, some patients experienced severe complications, even at the moderate dose used for this disease. This data suggest that proton therapy is a safe and effective treatment option for patients with meningiomas; however, further follow-up is necessary. Author Disclosure: E.D. Tanzler: None. C.G. Morris: None. J.M. Kirwan: None. W.M. Mendenhall: None. R.S. Malyapa: None.
2153 Impact of Radiation Therapy on Clinical Outcome of Meningiomas N.T. Nguyen,1 Y. Wang,1 L.L. Lyon,2 and J.L. Villano3; 1The Permanente Medical Group, Rancho Cordova, CA, 2Kaiser Permanente Division of Research, Oakland, CA, 3University of KY, Lexington, KY Purpose/Objective(s): Although meningioma is the most common primary brain tumor in the US, there is lack of standard guidelines in management due to limited data on clinical outcomes. Radiation therapy (RT) is used as treatment in <10% cases from population-based retrospective series. Materials/Methods: We performed descriptive and survival analyses of meningioma cases diagnosed 2001-2010 from the Kaiser Permanente Northern California Cancer Registry. Chart review extracted additional information on mortality, histology, imaging, tumor size, tumor site, treatment, and RT planning. Kaplan-Meier method was used to calculate overall survival (OS) and disease-free survival (DFS) and log-rank test to compare survival rates by variables. Cox proportional hazard models were used to analyze variables relative to endpoints. Results: One thousand nine hundred sixty-eight cases in 1792 patients with diagnosis of meningioma were analyzed. 55% of cases had histological confirmation. The 5- and 10-year OS and DFS for all groups were 76% and 61%, and 89% and 82%, respectively. Disease progression and recurrence presented in 10% of cases at 10 years, resulting in 4% diseasespecific mortality (DSM). Statistically significant prognostic factors of worse DFS were age 80, WHO grade 2-3, tumor size 18 mm, peritumoral edema (TE) on imaging, Simpson grades (SG) 4 or 5 and no surgery. Factors associated with significantly worse OS were age 60, male gender, tumor size 42 mm, TE, SG 4 or 5, no histology and no treatment (NT). SG 1-3 groups provided statistically the highest OS and DFS. There was no significant difference in DFS or OS for definitive RT vs surgery and adjuvant RT groups. Definitive RT showed significantly better OS than NT (HR Z 0.46; 95% CI, 0.21-0.98). Cases with progression or recurrence had 51% DSM with 65% of deaths associated with lack of salvage therapy. Salvage RT provided higher OS benefit compared to other salvage groups (HR Z 0.35; 95% CI, 0.14-0.91). 209 cases in 163 patients treated with RT were further analyzed. Modalities, using stereotactic radiosurgery (SRS), intensity modulated radiation therapy (IMRT), and 3-D conformal radiation therapy (CRT) for definitive, adjuvant or salvage therapy were
2152 NTCP Modeling of Hypofractionated Stereotactic Radiation Therapy (HSRT) for Patients With Subtotal Resection (STR) of WHO Grade 1 Meningioma: A Toxicity-Sparing More Convenient Treatment Method M. Yondorf, L. Zhou, S. Wang, J. Chang, A. Sabbas, B. Parashar, D. Nori, K. Chao, S. Pannullo, and A. Wernicke; Weill Cornell Medical College, New York, NY Purpose/Objective(s): HSRT for STR WHO grade I meningioma presents a more convenient treatment option for patients due to decreased overall treatment time (OTT). We use NTCP modeling to predict radiation toxicities in this patient population in HSRT as compared to standard fractionation schedule. Materials/Methods: Ten patients who underwent STR for newly diagnosed WHO grade I meningioma were retrospectively identified. Four plans for each patient (40 total plans) were created to compare the risk of toxicity based on the NTCP values. The fractionation of each plan is displayed in Table. GTV is defined as tumor cavity including residual disease. CTV and PTV were created by expanding GTV and CTV by 5mm, respectively. NTCP values were computed using standard models and toxicities calculated for normal brain tissue (NBT) (necrosis/infarction), Poster Viewing Abstract 2152; Table
Fractionation schedules and associated NTCP median risk of toxicity NTCP median risk of toxicity
1 2 3 4
Source for fractionation
Dose (Gy)
Fraction(s)
Total dose (Gy)
BED (Gy)
Brainstem
Chiasm
NBT
P value for NBT
RTOG 0539 Halasz, L 2011 Mahadevan, A 2011 WCMC Institutional HSRT Protocol
1.8 13 5 8
30 1 5 3
54 13 25 24
79.85 57.95 75.06 58.24
0.00% 0.00% 0.00% 0.00%
0.00% 0.00% 0.00% 0.00%
0.13% 0.01% 0.00% 0.25%
.054 .012 .19