title: Gamma Knife radiosurgery of large skull base meningiomas.
abstract: OBJECTIVE
  Stereotactic radiosurgery (SRS) has become a common treatment modality for intracranial meningiomas. Skull base meningiomas greater than 8 cm3 in volume have been found to have worse outcomes following SRS. When symptomatic, patients with these tumors are often initially treated with resection. For tumors located in close proximity to eloquent structures or in patients unwilling or unable to undergo a resection, SRS may be an acceptable therapeutic approach. In this study, the authors review the SRS outcomes of skull base meningiomas greater than 8 cm3 in volume, which corresponds to a lesion with an approximate diameter of 2.5 cm.
  
  
  METHODS
  The authors reviewed the data in a prospectively compiled database documenting the outcomes of 469 patients with skull base meningiomas treated with single-session Gamma Knife radiosurgery (GKRS). Seventy-five patients had tumors greater than 8 cm3 in volume, which was defined as a large tumor. All patients had a minimum follow-up of 6 months, but patients were included if they had a complication at any time point. Thirty patients were treated with upfront GKRS, and 45 were treated following microsurgery. Patient and tumor characteristics were assessed to determine predictors of new or worsening neurological function and tumor progression following GKRS.
  
  
  RESULTS
  After a mean follow-up of 6.5 years (range 0.5-21 years), the tumor volume was unchanged in 37 patients (49%), decreased in 26 patients (35%), and increased in 12 patients (16%). Actuarial rates of progression-free survival at 3, 5, and 10 years were 90.3%, 88.6%, and 77.2%, respectively. Four patients had new or worsened edema following GKRS, but preexisting edema decreased in 3 patients. In Cox multivariable analysis, covariates associated with tumor progression were 1) presentation with any cranial nerve (CN) deficit from III to VI (hazard ratio [HR] 3.78, 95% CI 1.91-7.45; p<0.001), history of radiotherapy (HR 12.06, 95% CI 2.04-71.27; p=0.006), and tumor volume greater than 14 cm3 (HR 6.86, 95% CI 0.88-53.36; p=0.066). In those patients with detailed clinical follow-up (n=64), neurological function was unchanged in 37 patients (58%), improved in 16 patients (25%), and deteriorated in 11 patients (17%). In multivariate analysis, the factors predictive of new or worsening neurological function were history of surgery (OR 3.00, 95% CI 1.13-7.95; p=0.027), presentation with any CN deficit from III to VI (OR 3.94, 95% CI 1.49-10.24; p=0.007), and decreasing maximal dose (OR 0.76, 95% CI 0.63-0.93; p=0.007). Tumor progression was present in 64% of patients with new or worsening neurological decline.
  
  
  CONCLUSIONS
  Stereotactic radiosurgery affords a reasonable rate of tumor control for large skull base meningiomas and does so with a low incidence of neurological deficits. Those with a tumor less than 14 cm3 in volume and without presenting CN deficit from III to VI were more likely to have effective tumor control.
authors.affiliation: Department of Neurosurgery.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Colin J
authors.initials: CJ
authors.lastname: Przybylowski
authors.forename: Mukherjee
authors.initials: M
authors.lastname: Sugoto
authors.forename: Francis
authors.initials: F
authors.lastname: Fezeu
authors.forename: Ahmed J
authors.initials: AJ
authors.lastname: Awad
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.forename: James H
authors.initials: JH
authors.lastname: Nguyen
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sheehan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018450:Disease Progression; D018572:Disease-Free Survival; D004307:Dose-Response Relationship, Radiation; D005260:Female; D006801:Humans; D008297:Male; D008579:Meningioma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D016634:Radiosurgery; D012189:Retrospective Studies; D019292:Skull Base Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D047368:Tumor Burden
keywords: CN = cranial nerve; CPA = cerebellopontine angle; GKRS = Gamma Knife radiosurgery; Gamma Knife radiosurgery; HR = hazard ratio; SRS = stereotactic radiosurgery; meningioma; microsurgery; outcome; recurrence; skull base; stereotactic radiosurgery