title: Intensity modulated radiotherapy (IMRT) for recurrent, residual, or untreated skull-base meningiomas: preliminary clinical experience.
abstract: OBJECTIVE
  To investigate the feasibility of using intensity modulated radiotherapy (IMRT) for complex-shaped benign meningiomas of the skull base and report clinical experience.
  
  
  METHODS
  Twenty patients with benign skull-base meningiomas WHO degrees I (histopathologically proven in 16/20) were treated with IMRT between June 1998 and August 1999. Each tumor was complex in shape and adherent to, or encompassed, organs at risk (cranial nerves, optic apparatus, and brainstem). All patients, immobilized in a customized head mask integrated into a stereotactic system, were planned on an inverse treatment planning system using 5 or 7 coplanar, equidistant beams and 5 intensity steps. Each treatment plan was verified extensively before treatment. Follow-up with MRI and clinical examination was performed at 6 and 18 weeks and every 6 months thereafter.
  
  
  RESULTS
  Target volumes ranged from 27 to 278 cc (median: 108 cc). Mean dose in 32 fractions ranged between 55.8 and 58.2 Gy. At median follow-up of 36 months (range: 31-43 months), pre-existing neurologic symptoms improved in 12/20 (60%), remained stable in 7/20 (35%), and worsened in 1 (5%) patient. Radiographic follow-up revealed significant tumor shrinkage 6 weeks post-IMRT in 2 patients and partial remission in 3 more patients at 9-17 months; other tumor volumes remained stable. There was no radiation-induced peritumoral edema, increase in tumor size, or new onset of neurologic deficits. Transient acute treatment side effects included nausea and vomiting and single occurrences of conjunctivitis/increased tearing and serous tympanitis.
  
  
  CONCLUSIONS
  IMRT in the treatment of central nervous system meningiomas is feasible and safe, offering highly conformal irradiation for complex-shaped skull-base tumors while sparing adjacent critical structures. If the tumor remissions seen here are found in the ongoing treatments, IMRT may be considered the treatment of choice for inoperable or subtotally resected meningiomas and for otherwise difficult-to-treat, complex-shaped tumors of the central nervous system adjacent to critical structures, with the potential of dose escalation for malignant tumors.
authors.affiliation: Department of Clinical Radiology, University of Heidelberg, Germany. pirzkall@radonc17.ucsf.edu
authors.forename: Andrea
authors.initials: A
authors.lastname: Pirzkall
authors.forename: Jürgen
authors.initials: J
authors.lastname: Debus
authors.forename: Peter
authors.initials: P
authors.lastname: Haering
authors.forename: Bernhard
authors.initials: B
authors.lastname: Rhein
authors.forename: Karl Heinz
authors.initials: KH
authors.lastname: Grosser
authors.forename: Angelika
authors.initials: A
authors.lastname: Höss
authors.forename: M
authors.initials: M
authors.lastname: Wannenmacher
mesh_terms: D000328:Adult; D000368:Aged; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007103:Immobilization; D008297:Male; D008577:Meningeal Neoplasms / Q000532:radiotherapy*; D008579:Meningioma / Q000532:radiotherapy*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000532:radiotherapy*; D018365:Neoplasm, Residual; D011832:Radiation Injuries / Q000209:etiology; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D020266:Radiotherapy, Conformal / Q000009:adverse effects / Q000379:methods*; D019291:Skull Base; D013238:Stereotaxic Techniques