title: Linac-based stereotactic radiosurgery (SRS) in the treatment of refractory trigeminal neuralgia: Detailed description of SRS procedure and reported clinical outcomes.
abstract: OBJECTIVE
  To present our linac-based SRS procedural technique for medically and/or surgically refractory trigeminal neuralgia (TN) treatment and simultaneously report our clinical outcomes.
  
  
  METHODS
  Twenty-seven refractory TN patients who were treated with a single fraction of 80 Gy to TN. Treatment delivery was performed with a 4 mm cone size using 7-arc arrangement with differential-weighting for Novalis-TX with six MV-SRS (1000 MU/min) beam and minimized dose to the brainstem. Before each treatment, Winston-Lutz quality assurance (QA) with submillimeter accuracy was performed. Clinical treatment response was evaluated using Barrow Neurological Institute (BNI) pain intensity score, rated from I to V.
  
  
  RESULTS
  Out of 27 patients, 22 (81%) and 5 (19%) suffered from typical and atypical TN, respectively, and had median follow-up interval of 12.5 months (ranged: 1-53 months). For 80 Gy prescriptions, delivered total average MU was 19440 ± 611. Average beam-on-time was 19.4 ± 0.6 min. Maximum dose and dose to 0.5 cc of brainstem were 13.4 ± 2.1 Gy (ranged: 8.4-15.9 Gy) and 3.6 ± 0.4 Gy (ranged: 3.0-4.9 Gy), respectively. With a median follow-up of 12.5 months (ranged: 1-45 months) in typical TN patients, the proportion of patients achieving overall pain relief was 82%, of which half achieved a complete pain relief with BNI score of I-II and half demonstrated partial pain reduction with BNI score of IIIA-IIIB. Four typical TN patients (18%) had no response to radiosurgery treatment. Of the patients who responded to treatment, actuarial pain recurrence free survival rates were approximately 100%, 75%, and 50% at 12 months, 15 months, and 24 months, respectively. Five atypical TN patients were included, who did not respond to treatment (BNI score: IV-V). However, no radiation-induced cranial-toxicity was observed in all patients treated.
  
  
  CONCLUSIONS
  Linac-based SRS for medically and/or surgically refractory TN is a fast, effective, and safe treatment option for patients with typical TN who had excellent response rates. Patients, who achieve response to treatment, often have durable response rates with moderate actuarial pain recurrence free survival. Longer follow-up interval is anticipated to confirm our clinical observations.
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Damodar
authors.initials: D
authors.lastname: Pokhrel
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Sumit
authors.initials: S
authors.lastname: Sood
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: McClinton
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Habeeb
authors.initials: H
authors.lastname: Saleh
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Badkul
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Hongyu
authors.initials: H
authors.lastname: Jiang
authors.affiliation: Department of Neurosurgery, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Timothy
authors.initials: T
authors.lastname: Stepp
authors.affiliation: Department of Neurosurgery, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Camarata
authors.affiliation: Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA.
authors.forename: Fen
authors.initials: F
authors.lastname: Wang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D063868:Patient Outcome Assessment; D011785:Quality Assurance, Health Care / Q000592:standards; D016634:Radiosurgery / Q000295:instrumentation* / Q000379:methods*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D012008:Recurrence; D016896:Treatment Outcome; D014277:Trigeminal Neuralgia / Q000473:pathology / Q000601:surgery*
keywords: linac-based SRS; neuralgia; outcome; toxicity; trigeminal