How to improve obliteration rates during volume-staged stereotactic radiosurgery for large arteriovenous malformations

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OBJECTIVE

The management of large-volume arteriovenous malformations (AVMs) with stereotactic radiosurgery (SRS) remains challenging. The authors retrospectively tested the hypothesis that AVM obliteration rates can be improved by increasing the percentage volume of an AVM that receives a minimal threshold dose of radiation.

METHODS

In 1992, the authors prospectively began to stage anatomical components in order to deliver higher single doses to AVMs > 15 cm3 in volume. Since that time 60 patients with large AVMs have undergone volume-staged SRS (VS-SRS). The median interval between the first stage and the second stage was 4.5 months (2.8–13.8 months). The median target volume was 11.6 cm3 (range 4.3–26 cm3) in the first-stage SRS and 10.6 cm3 (range 2.8–33.7 cm3) in the second-stage SRS. The median margin dose was 16 Gy (range 13–18 Gy) for both SRS stages.

RESULTS

AVM obliteration after the initial two staged volumetric SRS treatments was confirmed by MRI alone in 4 patients and by angiography in 11 patients at a median follow-up of 82 months (range 0.4–206 months) after VS-SRS. The post–VS-SRS obliteration rates on angiography were 4% at 3 years, 13% at 4 years, 23% at 5 years, and 27% at 10 years. In multivariate analysis, only ≥ 20-Gy volume coverage was significantly associated with higher total obliteration rates confirmed by angiography. When the margin dose is ≥ 17 Gy and the 20-Gy SRS volume included ≥ 63% of the total target volume, the angiographically confirmed obliteration rates increased to 61% at 5 years and 70% at 10 years.

CONCLUSIONS

The outcomes of prospective VS-SRS for large AVMs can be improved by prescribing an AVM margin dose of ≥ 17 Gy and adding additional isocenters so that ≥ 63% of the internal AVM dose receives more than 20 Gy.

ABBREVIATIONS ARE = adverse radiation effect; AVM = arteriovenous malformation; SRS = stereotactic radiosurgery; VS-SRS = volume-staged SRS.

Article Information

Correspondence Hideyuki Kano: University of Pittsburgh School of Medicine, Pittsburgh, PA. kanoh@upmc.edu.

INCLUDE WHEN CITING Published online July 20, 2018; DOI: 10.3171/2018.2.JNS172964.

Disclosures Dr. Lunsford is an Elekta AB stockholder and is a consultant for INSIGHTEC. The work described in this report was funded by a research grant to Dr. Kano from AB Elekta, Stockholm, Sweden.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Original first-stage SRS planning using GammaPlan version 10 for a large left occipital AVM. Lateral angiogram. B: Axial T1-weighted MR image: 7 × 8–mm isocenters, target volume 10.1 cm3, 20-Gy volume 5.7 cm3, 20-Gy volume rate 56%, and 12-Gy volume 18.1 cm3. Yellow outer line: 17-Gy line. Green inner line: 20-Gy line. Blue line: second-stage target. C: Simulated first-stage SRS planning. Lateral angiogram. D: Axial T1-weighted MR image; 20 × 4–mm isocenters, target volume 10.0 cm3, 20-Gy volume 7.1 cm3, 20-Gy volume rate 71%, and 12-Gy volume 16.0 cm3. Yellow outer line: 17-Gy line. Green inner line: 20-Gy line. Blue line: second-stage target. Multiple low-weighted additional isocenters placed within the volume described by 17 Gy can significantly increase the volume of the AVM receiving ≥ 20 Gy. Figure is available in color online only.

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    A: Kaplan-Meier curve for total obliteration on MRI or angiography after VS-SRS for large AVMs. B: Kaplan-Meier curve for total obliteration on angiography after VS-SRS for large AVMs with a margin dose of ≥ 17 Gy vs < 17 Gy. C: Kaplan-Meier curve for total obliteration on angiography after VS-SRS for large AVMs with the 20-Gy volume rate of ≥ 63% vs < 63% of the total target volume. D: In patients who underwent SRS as a primary treatment, Kaplan-Meier curve for total obliteration on angiography after VS-SRS for large AVMs with the 20-Gy volume rate of ≥ 63% vs < 63% of the total target volume.

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    A: Scatter plot illustrating the relationship between total target volume and margin dose, with total obliteration on angiography versus no total obliteration on angiography. B: Scatter plot illustrating the relationship between 20-Gy volume coverage and margin dose, with total obliteration on angiography versus no total obliteration on angiography. DSA = digital subtraction angiography; TO = total obliteration.

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