Gamma Knife surgery of pediatric gliomas

Clinical article

Restricted access

Object

While some low-grade pediatric gliomas may be cured with resection, many patients harbor tumors that cannot be completely resected safely, are difficult to access via an open surgical approach, or recur. Gamma Knife surgery may be beneficial in the treatment of these tumors.

Methods

The authors reviewed a consecutive series of 24 pediatric patients treated at the authors' institution between 1989 and 2011. All patients harbored tumors that were either surgically inaccessible or had evidence of residual or recurrent growth after resection. Progression-free survival was evaluated and correlated with clinical variables. Additional outcomes evaluated were clinical outcome, imaging response, and overall survival.

Results

Between 1989 and 2011, 13 male and 11 female patients (median age 11 years, range 4–18 years) with gliomas were treated. Tumor pathology was pilocytic astrocytoma (WHO Grade I) in 15 patients (63%), WHO Grade II in 4 (17%), and WHO Grade III in 1 (4%). The tumor pathology was not confirmed in 4 patients (17%). The mean tumor volume at the time of treatment was 2.4 cm3. Lesions were treated with a median maximum dose of 36 Gy, median of 3 isocenters, and median marginal dose of 15 Gy.

The median duration of imaging follow-up was 74 months, and the median duration of clinical follow-up was 144 months. The tumors responded with a median decrease in volume of 71%. At last follow up, a decrease in tumor size of at least 50% was demonstrated in 18 patients (75%) and complete tumor resolution was achieved in 5 (21%). Progression-free survival at last follow-up was achieved in 20 patients (83%). Progression was documented in 4 patients (17%), with 3 patients requiring repeat resection and 1 patient dying. The initial tumor volume was significantly greater in patients with disease progression (mean volume 4.25 vs 2.0 cm3, p < 0.001). Age, tumor pathology, tumor location, previous radiation, Karnofsky Performance Scale score, symptom duration, and target dosage did not differ significantly between the 2 groups.

Conclusions

Gamma Knife surgery can provide good clinical control of residual or recurrent gliomas in pediatric patients. Worse outcomes in the present series were associated with larger tumor volumes at the time of treatment.

Abbreviations used in this paper:GKS = Gamma Knife surgery; KPS = Karnofsky Performance Scale.

Article Information

Address correspondence to: Jason Sheehan, M.D., Ph.D., Box 800212, Charlottesville, Virginia 22908. email: jps2f@virginia.edu.

Please include this information when citing this paper: published online October 12, 2012; DOI: 10.3171/2012.9.PEDS12257.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graph showing progression-free survival.

  • View in gallery

    Axial MR images obtained before (left) and after (right) treatment of pilocytic astrocytoma. This 4-year-old girl (Case 5 in Table 1) had undergone 2 previous resections, with subsequent recurrence of the pilocytic astrocytoma seen in the cerebellar vermis. The second operation was complicated by a CSF leak requiring diversion through a ventriculoperitoneal shunt. The family was presented with the option of additional resection and declined. Gamma Knife surgery was then offered as an alternative. Long-term follow-up imaging demonstrates complete resolution of the enhancing tumor.

References

  • 1

    Boëthius JUlfarsson ERähn TLippittz B: Gamma knife radiosurgery for pilocytic astrocytomas. J Neurosurg 97:5 Suppl6776802002

    • Search Google Scholar
    • Export Citation
  • 2

    Bucy PCThieman PW: Astrocytomas of the cerebellum. A study of a series of patients operated upon over 28 years ago. Arch Neurol 18:14191968

    • Search Google Scholar
    • Export Citation
  • 3

    Clark BGSouhami LPla CAl-Amro ASBahary JPVillemure JG: The integral biologically effective dose to predict brain stem toxicity of hypofractionated stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 40:6676751998

    • Search Google Scholar
    • Export Citation
  • 4

    Garcia DMMarks JELatifi HRKliefoth AB: Childhood cerebellar astrocytomas: is there a role for postoperative irradiation?. Int J Radiat Oncol Biol Phys 18:8158181990

    • Search Google Scholar
    • Export Citation
  • 5

    Grabb PALunsford LDAlbright ALKondziolka DFlickinger JC: Stereotactic radiosurgery for glial neoplasms of childhood. Neurosurgery 38:6967021996

    • Search Google Scholar
    • Export Citation
  • 6

    Gururangan SFisher MJAllen JCHerndon JE IIQuinn JAReardon DA: Temozolomide in children with progressive low-grade glioma. Neuro Oncol 9:1611682007

    • Search Google Scholar
    • Export Citation
  • 7

    Hadjipanayis CGKondziolka DGardner PNiranjan ADagam SFlickinger JC: Stereotactic radiosurgery for pilocytic astrocytomas when multimodal therapy is necessary. J Neurosurg 97:56642002

    • Search Google Scholar
    • Export Citation
  • 8

    Hallemeier CLPollock BESchomberg PJLink MJBrown PDStafford SL: Stereotactic radiosurgery for recurrent or unresectable pilocytic astrocytoma. Int J Radiat Oncol Biol Phys 83:1071122012

    • Search Google Scholar
    • Export Citation
  • 9

    Heppner PASheehan JPSteiner LE: Gamma knife surgery for low-grade gliomas. Neurosurgery 57:113211392005

  • 10

    Hodgson DCGoumnerova LCLoeffler JSDutton SBlack PMAlexander E III: Radiosurgery in the management of pediatric brain tumors. Int J Radiat Oncol Biol Phys 50:9299352001

    • Search Google Scholar
    • Export Citation
  • 11

    Hoffman HJSoloniuk DSHumphreys RPDrake JMBecker LEDe Lima BO: Management and outcome of low-grade astrocytomas of the midline in children: a retrospective review. Neurosurgery 33:9649711993

    • Search Google Scholar
    • Export Citation
  • 12

    Kano HNiranjan AKondziolka DFlickinger JCPollack IFJakacki RI: Stereotactic radiosurgery for pilocytic astrocytomas part 2: outcomes in pediatric patients. J Neurooncol 95:2192292009

    • Search Google Scholar
    • Export Citation
  • 13

    Kida YKobayashi TMori Y: Gamma knife radiosurgery for low-grade astrocytomas: results of long-term follow up. J Neurosurg 93:Suppl 342462000

    • Search Google Scholar
    • Export Citation
  • 14

    Kidd EAMansur DBLeonard JRMichalski JMSimpson JRPerry A: The efficacy of radiation therapy in the management of grade I astrocytomas. J Neurooncol 76:55582006

    • Search Google Scholar
    • Export Citation
  • 15

    Larson DAWara WMEdwards MS: Management of childhood cerebellar astrocytoma. Int J Radiat Oncol Biol Phys 18:9719731990

  • 16

    Mayo CYorke EMerchant TE: Radiation associated brainstem injury. Int J Radiat Oncol Biol Phys 76:3 SupplS36S412010

  • 17

    Mirza BMønsted AHarding JOhlhues LRoed HJuhler M: Stereotactic radiotherapy and radiosurgery in pediatric patients: analysis of indications and outcome. Childs Nerv Syst 26:178517932010

    • Search Google Scholar
    • Export Citation
  • 18

    Nath SKCarmona RRose BSSimpson DRRussell MLawson JD: Observed magnetic resonance imaging changes in pediatric patients treated with stereotactic radiosurgery for intracranial tumors. Childs Nerv Syst 27:3994062011

    • Search Google Scholar
    • Export Citation
  • 19

    Packer RJAter JAllen JPhillips PGeyer RNicholson HS: Carboplatin and vincristine chemotherapy for children with newly diagnosed progressive low-grade gliomas. J Neurosurg 86:7477541997

    • Search Google Scholar
    • Export Citation
  • 20

    Prados MDEdwards MSRabbitt JLamborn KDavis RLLevin VA: Treatment of pediatric low-grade gliomas with a nitrosourea-based multiagent chemotherapy regimen. J Neurooncol 32:2352411997

    • Search Google Scholar
    • Export Citation
  • 21

    Rowe JGrainger AWalton LSilcocks PRadatz MKemeny A: Risk of malignancy after gamma knife stereotactic radiosurgery. Neurosurgery 60:60662007

    • Search Google Scholar
    • Export Citation
  • 22

    Snell JWSheehan JStroila MSteiner L: Assessment of imaging studies used with radiosurgery: a volumetric algorithm and an estimation of its error. Technical note. J Neurosurg 104:1571622006

    • Search Google Scholar
    • Export Citation
  • 23

    Somaza SCKondziolka DLunsford LDFlickinger JCBissonette DJAlbright AL: Early outcomes after stereotactic radiosurgery for growing pilocytic astrocytomas in children. Pediatr Neurosurg 25:1091151996

    • Search Google Scholar
    • Export Citation
  • 24

    Wang LWShiau CYChung WYWu HMGuo WYLiu KD: Gamma Knife surgery for low-grade astrocytomas: evaluation of long-term outcome based on a 10-year experience. J Neurosurg 105:Suppl1271322006

    • Search Google Scholar
    • Export Citation
  • 25

    Wolff JERytting MEVats TSZage PEAter JLWoo S: Treatment of recurrent diffuse intrinsic pontine glioma: the MD Anderson Cancer Center experience. J Neurooncol 106:3913972012

    • Search Google Scholar
    • Export Citation
  • 26

    Yen CPSheehan JSteiner MPatterson GSteiner L: Gamma knife surgery for focal brainstem gliomas. J Neurosurg 106:8172007

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 253 253 31
Full Text Views 76 73 0
PDF Downloads 116 106 0
EPUB Downloads 0 0 0

PubMed

Google Scholar