Radiation necrosis following gamma knife surgery: a case-controlled comparison of treatment parameters and long-term clinical follow up

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Object. Radiation necrosis is the only significant complication of gamma knife surgery (GKS). The authors studied treatment plan parameters in patients who had radiation necrosis to determine if risk factors for necrosis could be identified.

Methods. Between September 1994 and December 1998, 286 patients were treated with GKS by the senior author. Of the 243 patients who were suitable for analysis, 17 developed radiation necrosis and were prospectively followed. Concurrently, 17 patients without necrosis were randomly selected as case controls on the basis of histological findings in their lesions. Integral dose—volume histograms (DVHs) were calculated and dose—volume treatment parameters were determined. A comparison was made with both the established Kjellberg and Flickinger isonecrosis risk lines. Clinical outcome was assessed according to time to resolution of symptoms and return to normal radiographic appearance.

Conclusions. Treatment plan variables associated with the risk of necrosis were increased tumor volume (TV) integral dose, increased TV, and increased 10-Gy volume. Other risk factors included repeated radiosurgery to the same lesion and glioma histological findings. The Kjellberg 1% risk line predicted a 5% risk of radiation necrosis and the Flickinger 3% risk line predicted a 3% risk. The median time to development of necrosis was 4 months, and symptomatic and radiographic recovery times were 7.5 and 10.5 months, respectively. The median survival time in patients with necrosis was 30 months. The authors recommend prospective TV determination and DVH calculation for all radiosurgical treatments and the avoidance of repeated radiosurgical treatments to the same lesion when possible.

Article Information

Address reprint requests to: Lawrence S. Chin, M.D., 22 South Greene Street, Suite S-12-D, Baltimore, Maryland 21201. email: lchin@smail.umaryland.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Scatterplot of 10-Gy volumes, which were determined from treatment DVHs. The median value in each group is indicated by a horizontal line.

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    Case 1. Axial MR images demonstrating the temporal course of radiation necrosis. Upper Left: Axial T1-weighted MR image with contrast enhancement demonstrating a right frontal metastatic lesion before GKS. Upper Right: Three months later, the lesion has regressed, leaving a small residual area of enhancement. Lower Left: Fourteen months postradiosurgery, radiation necrosis has developed in the region of the tumor. The dense residual tumor can be seen in the necrotic region and the overall lesion demonstrates minimal mass effect. Lower Right: Twenty-two months postradiosurgery, the right frontal lesion has resolved, leaving residual enhancement and mild atrophy.

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    Isodose curves and treatment parameters calculated from DVH. Upper: The T1-weighted axial MR image from Fig. 2 upper left is shown with the isodose curves superimposed. The prescription isodose was the 75% line, and the 42% line corresponded to a dose of 10 Gy. Center: Graph showing the DVH calculated for the entire head volume. The PIV (1.7 cm3) is determined from the plot by finding the 75% mark (open arrowhead) and the corresponding TV. The 10-Gy volume corresponds to the 42% mark (solid arrowhead) and measures 3.4 cm3. Lower: Graph showing the DVH calculated for the TV. As evidenced from the graph, 100% of the TV (0.8 cm3) is treated at the 75% isodose line (arrow). The shaded volume under the curve represents the TVID.

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    Graphs comparing the Kjellberg 1% (solid line) and Flickinger 3% (dotted line) isonecrosis risk lines. Dose-diameter data in 34 patients studied using DVH were plotted against the aforementioned models. Upper: Data from 17 patients with necrosis. Lower: Data from 17 patients without necrosis. Our data confirm that the Kjellberg model predicts a 5% risk and the Flickinger a 3% risk. The squares represent the data points.

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