title: Hypofractionated stereotactic radiosurgery: a new treatment strategy for giant cavernous sinus hemangiomas.
abstract: OBJECTIVE Cavernous sinus hemangiomas (CSHs) are rare benign vascular tumors that arise from the dural venous sinuses lateral to the sella. Stereotactic radiosurgery (SRS) has emerged as a principal alternative to microresection for small- and medium-sized CSHs. Resection is a reasonable option for large (3-4 cm in diameter) and giant (> 4 cm in diameter) CSHs. However, management of giant CSHs remains a challenge for neurosurgeons because of the high rates of morbidity and even death that stem from uncontrollable and massive hemorrhage during surgery. The authors report here the results of their study on the use of hypofractionated SRS (H-SRS) to treat giant CSH. METHODS Between January 2008 and April 2014, 31 patients with a giant CSH (tumor volume > 40 cm3, > 4 cm in diameter) treated using CyberKnife radiosurgery were enrolled in a cohort study. Clinical status and targeted reduction of tumor volume were evaluated by means of serial MRI. The diagnosis for 27 patients was determined on the basis of typical imaging features. In 4 patients, the diagnosis of CSH was confirmed histopathologically. The median CSH volume was 64.4 cm3(range 40.9-145.3 cm3). Three or 4 sessions of CyberKnife radiosurgery were used with a prescription dose based on the intent to cover the entire tumor with a higher dose while ensuring dose limitation to the visual pathways and brainstem. The median marginal dose to the tumor was 21 Gy (range 19.5-21 Gy) in 3 fractions for 11 patients and 22 Gy (range 18-22 Gy) in 4 fractions for 20 patients. RESULTS The median duration of follow-up was 30 months (range 6-78 months) for all patients. Follow-up MRI scans revealed a median tumor volume reduction of 88.1% (62.3%-99.4%) at last examination compared with the pretreatment volume. Ten patients developed new or aggravated temporary headache and 5 experienced vomiting during the treatment; these acute symptoms were relieved completely after steroid administration. Among the 30 patients with symptoms observed before treatment, 19 achieved complete symptomatic remission, and 11 had partial remission. One patient reported seizures, which were controlled after antiepileptic drug administration. No radiation-induced neurological deficits or delayed complications were reported during the follow-up period. CONCLUSIONS Hypofractionated SRS was an effective and safe modality for treating giant CSH. Considering the risks involved with microsurgery, it is possible that H-SRS might be able to serve as a definitive primary treatment option for giant CSH.
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Xin
authors.initials: X
authors.lastname: Wang
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Huaguang
authors.initials: H
authors.lastname: Zhu
authors.affiliation: 3Department of Radiation Medicine, North Shore-Long Island Jewish Health System & Hofstra-North Shore-LIJ School of Medicine, Manhasset, New York.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Knisely
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Guanghai
authors.initials: G
authors.lastname: Mei
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Xiaoxia
authors.initials: X
authors.lastname: Liu
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Jiazhong
authors.initials: J
authors.lastname: Dai
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Ying
authors.initials: Y
authors.lastname: Mao
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Li
authors.initials: L
authors.lastname: Pan
authors.affiliation: Departments of1Neurosurgery and.
authors.forename: Zhiyong
authors.initials: Z
authors.lastname: Qin
authors.affiliation: Departments of1Neurosurgery and.|2CyberKnife, Huashan Hospital, Fudan University, Shanghai,China; and.
authors.forename: Enmin
authors.initials: E
authors.lastname: Wang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002426:Cavernous Sinus; D005260:Female; D005500:Follow-Up Studies; D006392:Hemangioma, Cavernous / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008577:Meningeal Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D008875:Middle Aged; D010865:Pilot Projects; D000069473:Radiation Dose Hypofractionation; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D047368:Tumor Burden; D055815:Young Adult
keywords: CS = cavernous sinus; CSH = cavernous sinus hemangioma; H-SRS = hypofractionated stereotactic radiosurgery; RION = radiation-induced optic neuropathy; SRS = stereotactic radiosurgery; cavernous sinus hemangioma; hypofractionation; stereotactic radiosurgery