https://openworks.mdanderson.org/sumexp23/1072/thumbnail.jp

Lee, Anna, M.D., MPH

Patel, Anika

Phan, Jack, M.D., Ph.D

Wang, Catherine, Ph.D.

English

OpenWorks @ MD Anderson

LINAC-Based Stereotactic Body Radiation Therapy for Benign Tumors of the Skull BaseAnika Patel, Anna Lee, M.D., MPH, Catherine Wang, Ph.D., Jack Phan M.D., Ph.D.Texas Tech Health Science Center El Paso, Paul L. Foster School of Medicine, El Paso, TXRadiation Oncology Department, University of Texas MD Anderson Cancer Center, Houston, TXBackgroundWhat is LINAC-based SBRT?• An external-beam radiation therapy (EBRT) that combines high definition multileaf collimators (MLC) based linear accelerators with image guidance to precisely deliver ablative radiation dose to localized tumors while sparing surrounding healthy tissues.Two primary techniques• Intensity modulated radiation therapy (including IMRT and VMAT) - more effective to give a better conformity index, uniformity index, and less dose in untargeted surrounding areas, especially for complex tumor geometries (head and neck cases)• Dynamic Conformation Arc - efficient and effective treatment for less complex tumor geometries, reduced risk of interplay errors induced by motion (lung cases)What tumors were treated?• Paragangliomas• Neural crest cell-derived tumors that are found in the jugular bulb, near the inner ear, and associated with the autonomic ganglia• Schwannomas• Arise from Schwann cells, the most common glial cells in the peripheral nerve system• Vestibular Schwannomas are associated with the vestibulocochlear nerve (CN VIII)• Myxoid Tumors• The most common soft tissue sarcomas and are derived from fibroblasts• These tumor types are benign or slow-growing and can be found at the base of the skull. The surrounding structures necessitate therapy that limits damage to untargeted areas.Conclusions• In this largest series to date, SBRT for benign skull base tumors resulted in excellent local control, minimal toxicity and overall improvement in presenting symptoms. • SBRT is a favorable treatment option for those who would otherwise have potentially significant cranial nerve injury following surgical resection. References1. El Majdoub F, Hunsche S, Igressa A, Kocher M, Sturm V, Maarouf M. Stereotactic LINAC-Radiosurgery for Glomus Jugulare Tumors: A Long-Term Follow-Up of 27 Patients. PLoS One. 2015 Jun 12;10(6):e0129057. doi: 10.1371/journal.pone.0129057. PMID: 26069957; PMCID: PMC4466539.2. Gigliotti MJ, Hasan S, Liang Y, Chen D, Fuhrer R, Wegner RE. A 10-year experience of linear accelerator-based stereotactic radiosurgery/radiotherapy (SRS/SRT) for paraganglioma: A single institution experience and review of the literature. J Radiosurg SBRT. 2018;5(3):183-190. PMID: 29988317; PMCID: PMC6018042.3. Guckenberger M, Andratschke N, Alheit H, Holy R, Moustakis C, Nestle U, Sauer O; Deutschen Gesellschaft für Radioonkologie (DEGRO). Definition of stereotactic body radiotherapy: principles and practice for the treatment of stage I non-small cell lung cancer. Strahlenther Onkol. 2014 Jan;190(1):26-33. doi: 10.1007/s00066-013-0450-y. Epub 2013 Sep 21. PMID: 24052011; PMCID: PMC3889283.4. Mizumatsu S, Ryu H, Nomura K, Yoshikawa S, Inoue N. Treating Low-Grade Myxofibrosarcoma With Stereotactic Body Radiation Therapy Using CyberKnife®. Cureus. 2021 Jul 14;13(7):e16393. doi: 10.7759/cureus.16393. PMID: 34408946; PMCID: PMC8363235.5. Patel AK, Rodríguez-López JL, Hirsch BE, Burton SA, Flickinger JC, Clump DA. Long term outcomes with linear accelerator stereotactic radiosurgery for treatment of jugulotympanic paragangliomas. Head Neck. 2021 Feb;43(2):449-455. doi: 10.1002/hed.26497. Epub 2020 Oct 13. PMID: 33047436.6. Tsao MN, Sahgal A, Xu W, De Salles A, Hayashi M, Levivier M, Ma L, Martinez R, Régis J, Ryu S, Slotman BJ, Paddick I. Stereotactic radiosurgery for vestibular schwannoma: International Stereotactic Radiosurgery Society (ISRS) Practice Guideline. J Radiosurg SBRT. 2017;5(1):5-24. PMID: 29296459; PMCID: PMC5675503.7. Wegner RE, Rodriguez KD, Heron DE, Hirsch BE, Ferris RL, Burton SA. Linac-based stereotactic body radiation therapy for treatment of glomus jugulare tumors. Radiother Oncol. 2010 Dec;97(3):395-8. doi: 10.1016/j.radonc.2010.09.004. Epub 2010 Oct 13. PMID: 20950881.Results• Thirty-one patients formed the cohort.• Median age was 51 years. Twenty-three cases were paragangliomas, 7 cases were schwannomas, and 1 case was a myxoid tumor.• Distribution of treated sites26 jugular foramen/jugulotympanicum3 carotid space1 hypoglossal canal1 petrous apex• Thirty patients had gross disease at the time of SBRT. One case was treated after resection.• Six patients were treated prior to SBRT among those with gross disease. Five surgically and one had prior fractionated radiation.• Indications for treatment were growth and/or symptomatic progression.• Hearing loss and tinnitus were the most common reported pre-treatment symptoms.MethodsWho?• Patients enrolled in the prospective skull base registry and treated between 2017 and 2023 were included in the study. All patients were evaluated for surgery and the risk of potential cranial nerve injury was the primary reason for consideration of radiation therapy.What?• This is a retrospective analysis of outcomes of patients presenting with a benign tumor of the skull base treated with LINAC-based SBRT.How?• Variables that were used to measure outcome included local control (LC), overall survival (OS), state of pre-treatment symptoms, and toxicity.• LC = radiographic evidence of lack of progression• Follow up interval = end of SBRT to last follow upTable 1. Characteristics of 31 patients undergoing SBRT for benign tumors at MD Anderson Cancer CenterIncidence Median (range)Age (years) 51 (23-83)Follow up (months) 20 (1-65)Sex N (%)Male 17 (55)Female 14 (45)Benign Tumor TypeParaganglioma 23 (74)Schwannoma 7 (23)Myxoid tumor 1 (3)LateralityRight 16 (52)Left 14 (45)Bilateral 1 (3)Treated sitesJugular foramen/ Jugulotympanicum26 (84)Carotid space 3 (10)Hypoglossal canal 1 (3)Petrous apex 1 (3)Disease statusGross disease 30 (97)Postoperative 1 (3)Prior treatment among those with gross diseaseSurgery 5 (16)Radiation 1 (3)Pre-treatment symptoms Stable/No Change Improved Worsened New SymptomTongue deviation 9 (29) 6 3 0 0Shoulder weakness 2 (6) 2 0 0 0Dysphagia 7 (23) 3 4 0 0Palpitations/Flushing 4 (13) 4 0 0 0Tinnitus 18 (58) 7 9 1 1Hearing loss 25 (81) 16 1 7 1Dizziness 9 (29) 2 7 0 0Otalgia 6 (19) 3 3 0 0Headache 3 (10) 0 2 1 0Hoarseness 8 (26) 4 4 0 0Response to treatment Improvement in symptoms 17 (55)No worsening symptoms 14 (45)Radiographically stable 31 (100)Toxicity following SBRTGrade 1 1 (3)Grade 2 2 (6)Results (continued)• Seventeen patients (55%) reported an improvement in symptoms and 14 patients (45%) reported no worsening symptoms.• The treated tumors were radiographically stable in all  patients treated for gross disease, and the patient treated adjuvantly remained disease free.• There was 1 grade 1 tinnitus, 1 grade 2 facial nerve palsy and 1 grade 2 nausea but no grade 3 or higher toxicities.Figure 1. Planning image showing dose distribution encompassing the tumor. This patient was treated for paraganglioma to 27Gy in 3 fractions. Figure 2. Planning image showing dose distribution encompassing the tumor. This patient was treated for paraganglioma to 27Gy in 3 fractions. 

LINAC-Based Stereotactic Body Radiation Therapy for Benign Tumors of the Skull Base

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LINAC-Based Stereotactic Body Radiation Therapy for Benign Tumors of the Skull Base

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