Trattamento SRS neurinoma dell`acustico def.def (4)(1)

Corso Teorico
Pratico di Audiologia
e
Vestibologia
La radiochirurgia stereotassica nel
trattamento
dei neurinomi vestibolari
Dr.ssa T. Pironti
Radioterapia
Dr.ssa G. Iorio
Neurochirurgia
Benevento 20 Febbraio 2016
«... una tecnica, a cielo chiuso, di distruzione
di un bersaglio intracranico
predeterminato con una singola frazione ,
ad alte dosi, di radiazioni ionizzanti ed una
precisione chirurgica, assicurata da un
apparato stereotassico ...»
Ma cosa significa allora trattamento stereotassico?
Tecnica terapeutica utilizzata per il trattamento di lesioni
individuate
attraverso metodi stereotassici accurati che, avvalendosi delle
tre
coordinate spaziali (x, y, z) consentono di erogare una dose
elevata
di radiazioni alla lesione grazie all’elevato gradiente di dose che
si crea fra il volume bersaglio e i tessuti sani circostanti.
MODALITA’ RADIOTERAPICHE IN STEREOTASSIA
Radiochirurgia (SRS):
ü unica frazione e casco invasivo
Radioterapia stereotassica frazionata (FSRT):
ü più di una frazione e maschera riposizionabile
1951: Leksell e Larsson (Uppsala-Sweden):
Ø termine e concetto di radiochirurgia stereotassica
1967: idea di sviluppare uno strumento per il neurochirurgo:
Ø nasce la Gamma Knife
(multiple sorgenti di cobalto radioattivo)
1969: primo trattamento con Gamma Knife di lesione APC
(Leksell)
... DALLA METÀ DEGLI ANNI ‘90 AD OGGI:
LINAC
Gamma knife
Cyberknife
Tomotherapy
Dispositivo di immobilizzazione/localizzazione:
individuare posizione e rapporti relativi della lesione con strutture circostanti
Il casco è fissato al capo del paziente con viti
(infiltrazione di anestetico locale) in SRS
Tecniche di fusione di immagine:
ØTC-RMN
ØRMN-RMN
Collimatore micro-multilamellare:
un attuatore multiasse, che agisce come obiettivo a
geometria variabile
48 lamelle di tungsteno da 3 mm modificano la forma del fascio di
fotoni per adattarsi alla forma del bersaglio.
Grande uniformità di dose!
Opzioni di trattamento
MicroSurgery
SRS
WAIT and SCAN
Improved preservation of hearing and facial nerve function in vestibular
schwannoma surgery via the retrosigmoid approach in a series of 200 patients.
Samii M, Gerganov V, Samii A.
J Neurosurg. 2006 Oct;105(4):527-35.
Neurosurg Clin N Am. 2013 Oct;24(4):521-30. doi: 10.1016/j.nec.2013.06.002. Epub 2013 Aug 2.
Radiosurgery for vestibular schwannomas
Régis J, Carron R, Delsanti C, Porcheron D, Thomassin JM, Murracciole X, Roche PH
This article investigates the role of radiosurgery and stereotactic radiotherapy in
the management of vestibular schwannomas (VS), reviewing the authors' own
prospective cohort and the current literature. For patients with large Stage IV VS
(according to the Koos classification), a combined approach with deliberate partial
microsurgical removal followed by radiosurgery to the residual tumor is proposed.
The authors' cohort is unique with respect to the size of the population and the
length of the follow-up, and demonstrates the efficacy and safety of VS
radiosurgery, with particular regard to its high rate of hearing preservation.
J Neurosurg Sci. 2013 Mar;57(1):23-44
Improving outcomes in patients with vestibular schwannomas:
microsurgery versus radiosurgery.
Sarmiento JM, Patel S, Mukherjee D, Patil CG.
Vestibular schwannomas (VSs) account for 6% of all intracranial tumors. Historically, VSs have
been treated with microsurgery (MS); however, stereotactic radiosurgery (SRS) has emerged as a
viable alternative. This review seeks to compare the tumor control rates, functional outcomes, and
costs associated with these two modalities. A focused review of the published literature (19662012) was conducted comparing outcomes between MS and SRS in those with VS. Outcomes of
interest included hearing preservation, facial nerve preservation, tumor control, and costeffectiveness. Three level 2 studies, eight level 3 studies, and several level 4 studies were reviewed
and assessed. Evidence from level 2 studies show that SRS (40-68%) results in higher rates of
serviceable hearing compared to MS (0-5%), and higher rates of facial nerve preservation are
likewise seen after SRS (98-100%) compared to MS (66-83%) in patients with tumors <3 cm in size.
Complications vary as expected by treatment modality, with CSF leak, tinnitus, and trigeminal
symptoms being among the most common complications following MS. Hydrocephalus, tinnitus,
and trigeminal symptoms were reported in a small percentage of patients after SRS. Tumor control
is comparable between MS and SRS for tumors <3cm in size. Total costs for MS can reach over two
times higher than for SRS, although long-term follow-up data is needed. SRS has been shown to be
efficacious and have a lower morbidity in most patients with tumors that are <3cm. SRS can be
considered as the primary modality of choice for treatment of most VS that are <3cm.
Linear accelerator radiosurgery for vestibular schwannomas.
Friedman WA, Bradshaw P, Myers A, Bova FJ.
J Neurosurg. 2006 Nov;105(5):657-61.
n July 1988 and August 2005, 390 patients with VSs were treated with LINAC-based radiosurgery
n One- and 2-year actuarial control rates were both 98%, and the 5-year actuarial control rate was 90%.
n Only four patients (1%) required surgery for tumor growth.
n Seventeen patients (4.4%) reported facial weakness
n 14 patients (3.6%) reported facial numbness after radiosurgery.
n The risk of these complications rose with increasing tumor volume or increasing radiosurgical dose to the
•
tumor periphery.
Since 1994, when doses were deliberately lowered to 1250 cGy, only two patients (0.7%) have experience
facial weakness and two (0.7%) have experienced facial numbness.
n Rischio di cancerogenesi
n Inefficace? Mancano follow up lunghi
n Deficit facciale e cocleare altrettanto frequenti che con la
microchirurgia
n Difficile operare dopo la radiochirurgia
McIver JI, Pollock BE. Radiation-induced tumor after stereotactic radiosurgery and
whole brain radiotherapy: case report and literature review.
J Neurooncol. 2004 Feb;66(3):301-5.
ü Shamisa A, Bance M, Nag S Tator C, Wong S, Noren G, Guha A. Glioblastoma
multiforme occurring in a patient treated with gamma knife surgery. Case report
and review of the literature.
J Neurosurg. 2001 May;94(5):816-21.
ü Management of radiation/radiosurgical complications and failures.
Roche PH, Noude Otolaryngol Clin North Am. 2012 Apr;45(2):367-74
Epub 2012
ü Radiosurgery and carcinogenesis risk.
Muracciole X., Resis J. Prog Neurol Surg.2008;21:207-13.
Conclusions:
the risk of radio-induced tumorigenesis is not clearly established with
single-dose radiosurgical technique.
Stereotact Funct Neurosurg. 2014;92(5):323-33. doi: 10.1159/000365225. Epub 2014 Sep 23.
The risk of malignancy anywhere in the body after linear accelerator (LINAC)
stereotactic radiosurgery.
Rahman M, Neal D, Baruch W, Bova FJ, Frentzen BH, Friedman WA.
CONCLUSIONS:
In a large population of SRS-treated patients, there was no increased risk of
malignancy compared to the general population.
World Neurosurg. 2014 Mar-Apr;81(3-4):594-9. doi: 10.1016/j.wneu.2013.10.043. Epub 2013 Oct 19.
The risk of malignancy anywhere in the body after linear accelerator (LINAC)
stereotactic radiosurgery.
Rahman M, Neal D, Baruch W, Bova FJ, Frentzen BH, Friedman WA.
CONCLUSIONS:
In a large population of SRS-treated patients, there was no increased risk of
malignancy compared to the general population.
RISCHIO DI TUMORI INDOTTI
DALLA RADIOCHIRURGIA
World Neurosurg. 2014 Mar-Apr;81(3-4):594-9.
doi: 10.1016/j.wneu.2013.10.043. Epub 2013 Oct 19.
Secondary neoplasms after stereotactic radiosurgery.
Patel TR, Chiang VL.
CONCLUSION:
The risk of developing an SRS-induced neoplasm is low but
not zero. Thus, long-term surveillance imaging is advised for
patients treated with SRS.
n Rischio di cancerogenesi
n Inefficace? Mancano follow up lunghi
n Deficit facciale e cocleare altrettanto frequenti che con la
microchirurgia
n Difficile operare dopo la radiochirurgia
Studio di meta-analisi che paragona risultati a distanza microchirurgia e
radiochirurgia (GK).
Kaylie DM, Horgan MJ, Delashaw JB, McMenomey SO.
Laryngoscope. 2000 Nov;110(11):1850-6.
Department of Otolaryngology--Head and Neck Surgery,
Oregon Health Sciences University,
Portland 97201-3098, USA.
Conclusions:
Surgery should remain the therapy of choice for acoustic
neuromas until tumor control rates can be established.
Conservative management, Gammaknife radiosurgery, and microsurgery for
acoustic neurinomas:
a systematic review of outcome and risk of three therapeutic options;
Iwao Yamakami et al, Dept.of Neurosurgery, Chiba, Japan
903 pt trattati con sola osservazione,
1475 con GK, 5005 con microchirurgia
38 studi
Osservazione : (3,1 anni): 51% crescita (1,8mm/anno)
20%operati 1/3 perde udito utile
GK: ridotto a 8% la crescita, ma il 4,6% viene in seguito operato
Microchirugia: 96% asportazione completa,1,8% recidiva mortalità:0,6%, disabilità 2,9%
Neurological Research, 2003
Conservative management, Gammaknife radiosurgery, and
microsurgery for acoustic neurinomas: a systematic review
of outcome and risk of three therapeutic options
Iwao Yamakami et al, Dept.of Neurosurgery, Chiba, Japan
In conclusione:
ØQuesti tumori crescono lentamente, ma raramente evitano l’intervento.
ØLa radiochirurgia arresta la crescita ed ottiene ottimo controllo di malattia.
ØLa chirurgia offre il miglior controllo di malattia, ma a spese di mortalità e
morbidità non trascurabili
Neurological Research, 2003
The art of management decision making:
from intuition to evidence-based medicine.
Sheth SA, Kwon CS, Barker FG 2nd.
Otolaryngol Clin North Am. 2012 Apr;45(2):333-51, viii. Epub 2012 Feb 23.
Review.
Conclusions: the article closes with a summary of the evidence-based
findings and suggestions for further research.
n Rischio di cancerogenesi
n Inefficace? Mancano follow up lunghi
n Deficit facciale e cocleare altrettanto frequenti che con la
microchirurgia
n Difficile operare dopo la radiochirurgia
J Neurosurg. 2007 Nov;107(5):913-6.
Effect of treatment plan quality on outcomes after
radiosurgery for vestibular schwannoma.
Beegle RD, Friedman WA, Bova FJ
Conclusions:
«treatment volume and treatment dose are significant predictors of
both facial weakness and facial numbness»
Prog Neurol Surg. 2008;21:108-18.
Facial nerve function insufficiency after radiosurgery versus microsurgery.
Tamura M, Murata N, Hayashi M, Roche PH, Régis J.
Stereotactic and Functional Neurosurgery,
Timone University Hospital, 264 boulevard Saint Pierre, Marseille Cedex 05,
France
Conclusions:
«symptoms related to the eye and taste either due to the injury of
the nervus intermedius or the VIIth motor nerve or both are much
more frequent after MS than after RS».
J. Clin Neurosci. 2012 Aug;19(8):1065-70.
doi: 10.1016/j.jocn.2012.01.015. Epub 2012 Jun 15.
Hearing preservation after LINAC radiosurgery and LINAC radiotherapy for vestibular schwannoma.
Fong BM, Pezeshkian P, Nagasawa DT, De Salles A, Gopen Q, Yang I.
Linear accelerators (LINAC) can deliver both radiosurgery and fractionated radiotherapy. In this systematic
analysis, we compare hearing preservation in patients with vestibular schwannomas (VS) treated with either
LINAC-based radiotherapy (SRT) or LINAC-based radiosurgery (SRS), with an emphasis on the prognostic
implications of tumor size and patient age. A total of 400 patients met our criteria for LINAC SRS, with an
average hearing preservation rate of 66.3%. Patients with smaller tumors (<3.0 cm(3)) treated with SRS had
similar hearing preservation rates to those with larger tumors. However, younger patients (<55 years)
demonstrated improved hearing preservation compared to older patients (≥55 years). When comparing LINAC
SRS to LINAC SRT directly, hearing preservation was similar in patients with smaller tumors. However, patients
with larger tumors (≥3.0cm(3)) who received SRT had higher hearing preservation rates than those who
received SRS. A total of 629 patients met our criteria for LINAC SRT, with an average hearing preservation rate
of 75.3%. Patients with larger tumors who received SRT had better hearing outcomes than those with smaller
tumors, while there was no significant difference in hearing preservation in younger patients compared to older
patients. When comparing LINAC SRS to LINAC SRT directly, younger patients had similar hearing preservation
rates. However, older patients who received SRT had improved hearing preservation compared to those who
received SRS. In a direct comparison of average hearing preservation, patients who received SRT had higher
hearing preservation rates than those who underwent SRS. Prospective studies will be needed to further
characterize radiation dose and other variables.
Patient outcomes after vestibular schwannoma management:
a prospective
radiosurgery.
comparison
of
microsurgical
resection
and
stereotactic
Pollock B. Dept.of Neurological Surgery,
MAYO CLINIC USA
Studio prospettico non randomizzato: due gruppi omogenei per
deficit uditivo, deficit associati e dimensioni della lesione
82 pz: 36 operati (età 48,2 ) 46 irradiati (età 53,9)
Follow-up medio: 42 mesi (12-62)
Facciale ed udito utile conservati nel gruppo SRS
(migliore Dizziness Handicap Inventory scores)
Il gruppo chirurgico: declino nel Health Status Questionnaire
Nessuna differenza nel controllo di malattia
Neurosurgery, 2006
Neurosurgery. 2006 Jul;59(1):77-85; discussion 77-85.
Patient outcomes after vestibular schwannoma
management: a prospective comparison of microsurgical
resection and stereotactic radiosurgery.
Pollock BE, Driscoll CL, Foote RL, Link MJ, Gorman DA, Bauch CD,
Mandrekar JN, Krecke KN, Johnson CH
Department of Neurological Surgery, Mayo Clinic College of Medicine,
Rochester, Minnesota 55905, USA. [email protected]
…early outcomes were better for VS patients undergoing
stereotactic radiosurgery compared with surgical resection
(Level 2 evidence). Unless long-term follow-up evaluation
shows frequent tumor progression at currently used radiation
doses, radiosurgery should be considered the best
management strategy for the majority of VS patients.
J Neurosurg. 2011 Feb;114(2):400-13.
Department of Neurosurgery, University of Florida, Gainesville, Florida 32610, USA.
Decision analysis of treatment options for vestibular schwannoma
Whitmore RG, Urban C, Church E, Ruckenstein M, Stein SC, Lee JY.
Conclusions:
patients treated with radiosurgery have an overall better QOL than those treated
with either microsurgery or those investigated further with serial imaging. The
authors found that the complications associated with wait-and-scan and
microsurgery treatment strategies negatively impacted patient lives more than the
complications from radiosurgery.
n Rischio di cancerogenesi
n Inefficace? Mancano follow up lunghi
n Deficit facciale e cocleare altrettanto frequenti che con la
microchirurgia
n Difficile operare dopo la radiochirurgia
NEURINOMA
VESTIBOLARE
Intervento dopo la
radiochirurgia
Ø 11 casi pubblicati da Pittsburgh sul JNS
Ø Opinioni divise 50/50
Ø Esperienza negativa nella liberazione del facciale dalla
superficie del tumore:
Brakmann, Samii
Ø No esperienza personale sui casi trattati
LA RADIOCHIRURGIA STEREOTASSICA
NEL TRATTAMENTO DEI NEURINOMI VESTIBOLARI:
NOSTRA CASISTICA
Dal 2008 a tutt’oggi
n° casi trattati: 9
Età compresa tra 65 ed 82 anni
Diametro volume lesione compreso tra 1.3 e 2.9
Media dose 12-14 Gy
LA RADIOCHIRURGIA STEREOTASSICA
NEL TRATTAMENTO DEI NEURINOMI VESTIBOLARI:
NOSTRA CASISTICA
DEFICIT N. CRANICI PREESISTENTI:
acustico 1,7 %
facciale
6,8 %
trigemino 24,1 %
DEFICIT N. CRANICI POST TRATTAMENTO:
acustico 0%
facciale
0%
trigemino 0.15%
CONTROLLO LOCALE
4 lesioni su 9 sono diminuite di volume
5 lesioni sono rimaste invariate, manifestando
solo alterazione di segnale attribuibile a necrosi
centrale
Nessun caso è aumentato di volume
S R S vs M S
ü Take home message:
ü Sovrapponibilità degli outcome come controllo locale
ü Minore morbidità per la SRS per tumori < 3 cm
ü Maggiori costi per la chirurgia
ü Aumento rischio cancerogenetico a lunga distanza (?)
Dunque
ü Accurata selezione dei pazienti
ü Necessità di un team multidisciplinare affiatato
ü Disponibilità di tutte le metodiche nello stesso centro