Outcomes of Gamma Knife Surgery retreatment for growing vestibular schwannoma and review of the literature.

OBJECTIVE: Gamma Knife surgery has become an accepted treatment for small to medium­size vestibular schwannoma with a high rate of tumor control and good clinical outcome. When GKS treatment fails to stop tumor growth, GKS retreatment can be proposed in selected cases. This retrospective study examines the clinical and tumor control outcome after the second GKS retreatment for the same vestibular schwannomas. METHODS: A total of 14 consecutive vestibular schwannomas patients retreated with 2nd GKS were included: The median time interval between GKS treatments was 44 months, and the median follow­up duration after last GKS retreatment was 60 months. The median marginal dose used for the first and second treatments was 12 Gy. The median tumor volume at the initial GKS was 2.4cc (range 0.27-3.8) and was 3.8cc (range 1.21-7.6) at the GKS retreatment. RESULTS: At the last follow­up, 93% (13 patients) had tumor growth control, decreased in 4, remained unchanged in 9, and increased tumor size in one patient. New facial or severe trigeminal palsy did not occur after the second GKS retreatment. The hearing was not preserved except in one patient post-GKS retreatment. CONCLUSIONS: GKS retreatment after the failure of initial GKS to control vestibular schwannomas growth appears to be an effective strategy and can be proposed as an alternative to microsurgery when the tumor volume remains within the usual radiosurgical range.

Long-term effectiveness and safety of stereotactic gamma knife surgery as a primary sole treatment in the management of glomus jagulare tumor.

OBJECTIVE: This study aims to report and confirm long-term effectiveness and safety of stereotactic Gamma Knife Surgery as a primary sole treatment in the management of 40 glomus jagulare tumors patients. PATIENTS AND METHODS: Retrospective analysis of clinical and radiological outcomes of 40 GJTs consecutive patients treated with GKS as primary sole treatment at International Medical Center (IMC), Cairo-Egypt from the beginning of 2005 till the end of 2014,with mean follow-up period of 84 months (range 36-156 months), mean tumor volume was 6.5 cc, and mean peripheral radiation dose of 15 Gy, to mean isodose curve of 38%. RESULTS: The most common neurological deficit at initial evaluation was bulbar symptoms in 24 patients, followed by pulsatile tinnitus in 22, deterioration of hearing in 20 patients. The overall clinical control achieved in 92.5% of patients, while actuarial tumor size control rate post- GKS was 97.5% at 3 years, 97% at 5 years and 92% at 10 years of follow-up period. CONCLUSIONS: Gamma knife surgery could be used effectively and safely as a primary sole treatment tool in the management of glomus jugulare tumors.

An intermediate term benefits and complications of gamma knife surgery in management of glomus jugulare tumor.

Glomus tumors are rare skull base slow-growing, hypervascular neoplasms that frequently involve critical neurovascular structures, and delay in diagnosis is frequent. Surgical removal is rarely radical and is usually associated with morbidity or mortality. Gamma knife surgery (GKS) has gained an increasing dependable role in the management of glomus jugulare tumors, with high rate of tumor growth control, preserving or improving clinical status and with limited complications. This study aims to evaluate intermediate term benefits and complications of gamma knife surgery in management of twenty-two patients bearing growing glomus jugulare tumors at the International Medical Center (IMC), Cairo, Egypt, between 2005 and 2011. The mean follow-up period was 56 months (range 36-108 months); there were 3 males, 19 females; mean age was 43.6 years; 15 patients had GKS as the primary treatment; 2 patients had surgical residuals; 2 had previous radiation therapy; and 3 previously underwent endovascular embolization. The average tumor volume was 7.26 cm3, and the mean marginal dose was 14.7 Gy. Post gamma knife surgery through the follow-up period neurological status was improved in 12 patients, 7 showed stable clinical condition and 3 patients developed new moderate deficits. Tumor volume post GKS was unchanged in 13 patients, decreased in 8, and showed tumor regrowth in 1 patient. Tumor progression-free survival in our studied patients was 95.5% at 5 and 7 years of the follow-up period post GKS. Gamma knife surgery could be used safely and effectively with limited complications as a primary management tool in the treatment of glomus jugulare tumors controlling tumor growth with preserving or improving clinical status especially those who do not have significant cranial or cervical extension, elderly, and surgically unfit patients; moreover, it is safe and highly effective as adjuvant therapy as well.

Stereotactic Gamma Knife surgery safety and efficacy in the management of symptomatic benign confined cavernous sinus meningioma.

BACKGROUND: Considering the proximity to cranial nerves from II to VI and the internal carotid artery microsurgery for cavernous sinus meningioma (CSM) has its limits of complete resection, with high potential tumor recurrences, cranial nerve and vascular morbidity. Gamma Knife surgery (GKS) is an advanced modality as primary treatment for patients harboring symptomatic benign confined CSM as well as adjuvant therapy to postoperative residual tumor giving a high rate of tumor control, stabilizing or even improving clinical condition with low morbidity. MATERIALS AND METHODS: The aim of this study is to evaluate the safety and efficacy of GKS used in the management of 62 patients with symptomatic benign confined CSM < 3 cm in maximum diameters treated at the International Medical Centre (IMC), Cairo, Egypt, from 2005 to end of 2012, with mean follow-up period of 36 months (range, 24-96 months) by reviewing their clinical and radiological data. For 51 patients GKS was performed as a primary treatment. The diagnosis was based on typical clinical and imaging findings and in 11 patients GKS was used as adjuvant to post-operative tumor residual with histological confirmation. RESULTS: There were 43 females and 19 males. The median age at the time of treatment was 48 years. The mean tumor volume was 5.7 cc, the mean tumor marginal radiation dose was 14.4 Gy, the mean isodose line was 38 %, and the mean tumor coverage was 94.4 %. The optic pathway received < 8 Gy and the brain stem < 10 Gy. At most recent follow-up, 57 patients (92 %) had stable or improved cranial nerve deficits. Post-GKS cranial nerve complications were detected in five patients (8 %). Tumor volume was controlled in 60 patients (96 %) at most recent follow-up MRI; 12 patients had a reduction in tumor size and 42 had stable tumor size, while tumor size progression was detected in two patients. The tumor progression-free survival at 3 and 5 years in 40 patients who completed at least 5 years of follow-up was 95 %. CONCLUSIONS: Gamma Knife surgery is a safe and effective option for the treatment of cavernous sinus meningioma not only as an adjuvant to surgery but also as an alternative to surgical removal in tumors confined mainly to the cavernous sinus.

The safety and efficacy of gamma knife surgery in management of glomus jugulare tumor.

BACKGROUND: Glomus jugulare is a slowly growing, locally destructive tumor located in the skull base with difficult surgical access. The operative approach is, complicated by the fact that lesions may be both intra and extradural with engulfment of critical neurovascular structures. The tumor is frequently highly vascular, thus tumor resection entails a great deal of morbidity and not infrequent mortality. At timeslarge residual tumors are left behind. To decrease the morbidity associated with surgical resection of glomus jugulare, gamma knife surgery (GKS) was performed as an alternative in 13 patients to evaluate its safety and efficacy. METHODS: A retrospective review of 13 residual or unresectable glomus jagulare treated with GKS between 2004 and 2008.. Of these, 11 patients underwent GKS as the primary management and one case each was treated for postoperative residual disease and postembolization. The radiosurgical dose to the tumor margin ranged between 12-15 Gy. RESULTS: Post- gamma knife surgery and during the follow-up period twelve patients demonstrated neurological stability while clinical improvement was achieved in 5 patients. One case developed transient partial 7th nerve palsy that responded to medical treatment. In all patients radiographic MRI follow-up was obtained, the tumor size decreased in two cases and remained stable (local tumor control) in eleven patients. CONCLUSIONS: Gamma knife surgery provids tumor control with a lowering of risk of developing a new cranial nerve injury in early follow-up period. This procedure can be safely used as a primary management tool in patients with glomus jugulare tumors, or in patients with recurrent tumors in this location. If long-term results with GKS are equally effective it will emerge as a good alternative to surgical resection.