Stereotactic radiosurgery for trigeminal pain secondary to recurrent malignant skull base tumors

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OBJECTIVE

The objective of this study was to assess outcomes after Gamma Knife radiosurgery (GKRS) re-irradiation for palliation of patients with trigeminal pain secondary to recurrent malignant skull base tumors.

METHODS

From 2009 to 2016, 26 patients who had previously undergone radiation treatment to the head and neck received GKRS for palliation of trigeminal neuropathic pain secondary to recurrence of malignant skull base tumors. Twenty-two patients received single-fraction GKRS to a median dose of 17 Gy (range 15–20 Gy) prescribed to the 50% isodose line (range 43%–55%). Four patients received fractionated Gamma Knife Extend therapy to a median dose of 24 Gy in 3 fractions (range 21–27 Gy) prescribed to the 50% isodose line (range 45%–50%). Those with at least a 3-month follow-up were assessed for symptom palliation. Self-reported pain was evaluated by the numeric rating scale (NRS) and MD Anderson Symptom Inventory–Head and Neck (MDASI-HN) pain score. Frequency of as-needed (PRN) analgesic use and opioid requirement were also assessed. Baseline opioid dose was reported as a fentanyl-equivalent dose (FED) and PRN for breakthrough pain use as oral morphine-equivalent dose (OMED). The chi-square and Student t-tests were used to determine differences before and after GKRS.

RESULTS

Seven patients (29%) were excluded due to local disease progression. Two experienced progression at the first follow-up, and 5 had local recurrence from disease outside the GKRS volume. Nineteen patients were assessed for symptom palliation with a median follow-up duration of 10.4 months (range 3.0–34.4 months). At 3 months after GKRS, the NRS scores (n = 19) decreased from 4.65 ± 3.45 to 1.47 ± 2.11 (p < 0.001); MDASI-HN pain scores (n = 13) decreased from 5.02 ± 1.68 to 2.02 ± 1.54 (p < 0.01); scheduled FED (n = 19) decreased from 62.4 ± 102.1 to 27.9 ± 45.5 mcg/hr (p < 0.01); PRN OMED (n = 19) decreased from 43.9 ± 77.5 to 10.9 ± 20.8 mg/day (p = 0.02); and frequency of any PRN analgesic use (n = 19) decreased from 0.49 ± 0.55 to 1.33 ± 0.90 per day (p = 0.08). At 6 months after GKRS, 9 (56%) of 16 patients reported being pain free (NRS score 0), with 6 (67%) of the 9 being both pain free and not requiring analgesic medications. One patient treated early in our experience developed a temporary increase in trigeminal pain 3–4 days after GKRS requiring hospitalization. All subsequently treated patients were given a single dose of intravenous steroids immediately after GKRS followed by a 2–3-week oral steroid taper. No further cases of increased or new pain after treatment were observed after this intervention.

CONCLUSIONS

GKRS for palliation of trigeminal pain secondary to recurrent malignant skull base tumors demonstrated a significant decrease in patient-reported pain and opioid requirement. Additional patients and a longer follow-up duration are needed to assess durability of symptom relief and local control.

ABBREVIATIONS BNI = Barrow Neurological Institute; FED = fentanyl-equivalent dose; GKE = Gamma Knife Extend; GKRS = Gamma Knife radiosurgery; MDACC = MD Anderson Cancer Center; MDASI-HN = MD Anderson Symptom Inventory–Head and Neck; NRS = numeric rating scale; OMED = oral morphine-equivalent dose; PRN = as needed; SRS = stereotactic radiosurgery; TN = trigeminal neuralgia.

Article Information

Correspondence Jack Phan: The University of Texas MD Anderson Cancer Center, Houston, TX. jphan@mdanderson.org.

INCLUDE WHEN CITING Published online April 27, 2018; DOI: 10.3171/2017.11.JNS172084.

Disclosures Dr. Frank reports being a consultant to Varian.

© AANS, except where prohibited by US copyright law.

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Figures

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    Images from a patient treated with single-fraction GKRS for TN. This patient was previously treated for adenoid cystic carcinoma of the floor of the mouth. The patient presented with right-sided facial pain along the V2 and V3 distribution and was found to have recurrent tumor involving the skull base. A: Treatment-planning T1-weighted postcontrast MR image showing tumor involving Meckel’s cave (arrow). B: Contrast enhancement of trigeminal nerve disease at the level of the prepontine cistern (arrows). C: GKRS treatment plan. The patient was treated at 16 Gy in 1 fraction to the 50% isodose line. The brainstem (turquoise contour) does not receive any high-dose radiation. D: At 6 months, pain level decreased from 7/10 to 1/10; the hydromorphone requirement decreased from 2 mg every 2 hours to 2 mg twice daily PRN. Posttreatment MRI showed no residual contrast enhancement in Meckel’s cave (dashed circle). Figure is available in color online only.

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    Images obtained in a patient treated with multifraction GKE for salivary gland carcinoma recurrent to the right skull base after presenting with right facial numbness and pain. A: Extensive tumor involvement of the cavernous sinus and Meckel’s cave with invasion into the right brainstem (dashed line delineates superior to inferior extent of tumor) precluded use of single-fraction GKRS. B: GKE stereotactic head frame utilizing a noninvasive fixation system attached to the patient via a vacuum-sealed mouthpiece (asterisk). C: Volumetric contrast-enhanced treatment-planning MRI. The patient was treated at 21 Gy in 3 fractions to the 46% isodose line. The volume of uninvolved brainstem (pink contour) that received 16 Gy was kept below 0.3 cm3. D: At 6 months after treatment, pain was reduced from 4/10 on morphine sulfate controlled-release and oxycodone and gabapentin to 0/10 on gabapentin alone. MRI showed stable enhancement at the level of the right Meckel’s cave (dashed arrow) with decreased enhancement and compression of the right lateral brainstem (dashed oval). Figure is available in color online only.

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