Outcomes of stereotactic radiosurgery for foramen magnum meningiomas: an international multicenter study

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OBJECTIVE

Meningiomas are the most common benign extramedullary lesions of the foramen magnum; however, their optimal management remains undefined. Given their location, foramen magnum meningiomas (FMMs) can cause significant morbidity, and complete microsurgical removal can be challenging. Anterior and anterolateral FMMs carry greater risks with surgery, but they comprise the majority of these lesions. As an alternative to resection, stereotactic radiosurgery (SRS) has been used to treat FMMs in small case series. To more clearly define the outcomes of SRS and to delineate a rational management paradigm for these lesions, the authors analyzed the safety and efficacy of SRS for FMM in an international multicenter trial.

METHODS

Seven medical centers participating in the International Gamma Knife Research Foundation (IGKRF) provided data for this retrospective cohort study. Patients who were treated with Gamma Knife radiosurgery and whose clinical and radiological follow-up was longer than 6 months were eligible for study inclusion. Data from pre- and post-SRS radiological and clinical evaluations were analyzed. Stereotactic radiosurgery treatment variables were recorded.

RESULTS

Fifty-seven patients (39 females and 18 males, with a median age of 64 years) met the study inclusion criteria. Thirty-two percent had undergone prior microsurgical resection. Patients most frequently presented with cranial neuropathy (39%), headache (35%), numbness (32%), and ataxia (30%). Median pre-SRS tumor volume was 2.9 cm3. Median SRS margin dose was 12.5 Gy (range 10–16 Gy). At the last follow-up after SRS, 49% of tumors were stable, 44% had regressed, and 7% had progressed. Progression-free survival rates at 5 and 10 years were each 92%. A greater margin dose was associated with a significantly increased likelihood of tumor regression, with 53% of tumors treated with > 12 Gy regressing. Fifty-two percent of symptomatic patients noted some clinical improvement. Adverse radiation effects were limited to hearing loss and numbness in 1 patient (2%).

CONCLUSIONS

Stereotactic radiosurgery for FMM frequently results in tumor control or tumor regression, as well as symptom improvement. Margin doses > 12 Gy were associated with increased rates of tumor regression. Stereotactic radiosurgery was generally safe and well tolerated. Given its risk-benefit profile, SRS may be particularly useful in the management of small- to moderate-volume anterior and anterolateral FMMs.

ABBREVIATIONS ARE = adverse radiation effect; FMM = foramen magnum meningioma; GKRS = Gamma Knife radiosurgery; SRS = stereotactic radiosurgery.

Article Information

Correspondence Jason P. Sheehan, Department of Neurological Surgery, University of Virginia Medical Center, PO Box 800212, Charlottesville, VA 22908. email: jsheehan@virginia.edu.

INCLUDE WHEN CITING Published online September 1, 2017; DOI:10.3171/2017.3.JNS163008.

Disclosures Dr. Grills reports service on the board of directors for and stock ownership in Greater Michigan Gamma Knife and, through her institution, the receipt of funding for non–study-related research from Elekta. Dr. Lunsford has stock ownership in Elekta AB and is a consultant for Insightec.

© AANS, except where prohibited by US copyright law.

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Figures

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    Postcontrast T1-weighted MR images obtained in a 61-year-old patient with an FMM treated with GKRS. A: Pretreatment imaging revealed an incidentally discovered anterolateral FMM (arrowhead) with a total volume of 1.8 cm3. B: Six months after SRS (14 Gy), imaging revealed a significant decrease in lesion size (arrowhead) with no AREs.

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    Kaplan-Meier analyses of tumor progression and regression after SRS for FMMs. A: In analyzing tumor growth, progression-free survival at 2, 5, 8, and 10 years after SRS was found to be 100%, 92%, 92%, and 92%, respectively. B: In analyzing tumor regression, the cumulative proportion of patients with regressing tumors at 2, 5, 8, and 10 years after SRS was found to be 43%, 54%, 54%, and 69%, respectively.

  • View in gallery

    Kaplan-Meier analysis of tumor regression in patients who received a margin dose ≤ 12 Gy and those who received > 12 Gy. Although more patients among the group receiving > 12 Gy demonstrated treatment responses (53% vs 33%), this difference was not statistically significant according to a Cox proportional hazards model (p = 0.07).

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