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Michael Torrens Department of Gamma Knife Radiosurgery and Neurosurgery Clinic, Hygeia Hospital, Athens. ABSTRACT Gamma Knife radiosurgery has an established therapeutic role in neurosurgery with around 250,000 cases treated and a follow up over 20 years. The success and control rates have improved as more experience of appropriate dosage has been gained and as more planning accuracy has been achieved by new machines, new computer programs and better quality control. The currently quoted control rates for benign lesions less than 3cm diameter are: astrocytoma grade 1 – 92%, astrocytoma grade 2 – 87%, acoustic neuroma (vestibular schwannoma) – 96%, meningioma – 96 to 99%, non-secretory pituitary adenoma – 92%, GH and ACTH secreting adenomas – 80%, prolactin secreting adenomas – 40%, chordoma and chondrosarcoma – 73%, glomus tumour 100%, epilepsy (mesial temporal sclerosis) – 81%, trigeminal neuralgia – 83%, parkinsonian tremor 88%, parkinsonian rigidity/bradykinesia – 66%, obsessive compulsive neurosis – 60%, arterio-venous malformation 90%, cavernoma – 86%, uveal melanoma – 84%. In malignant glioblastoma, mean survival of 116 weeks has been described. In cerebral metastases the lesions can be controlled in almost every case so that survival then depends on the extracerebral disease. In many cases these various results have been achieved after failure of surgery or radiotherapy treatments. Complications are significantly less than with microsurgery, radiotherapy or LINAC based radiosurgery. The method is more cost effective than traditional surgical treatment and is also more acceptable for the patients.
Figure 1. Leksell Gamma Knife Perfexion
INTRODUCTION The Leksell Gamma Knife (fig. 1) is a well known treatment method, especially to neurosurgeons, but there exist some misconceptions which it is the intention of this paper to clarify as well as to review the contemporary indications for Gamma Knife treatment. Gamma Knife is not a form of radiotherapy. Radiotherapy relies for its effect on the differential radiosensitivity of neoplastic tissue and the ability of normal tissue to repair itself. Gamma Knife treatment is a form of surgical ablation that competes with microsurgery by producing targeted cell death. This results in shrinkage of tumours (including ‘radioresistant’ ones),
While surrounding damage may not matter much in a frontal lobe metastasis. The rays all meet at one point.1 Treatment plan with LINAC Fig 2. . Mechanism of action Radiation from 201 separate cobalt sources is finely collimated. For this reason it is not always appropriate to quote results from older reviews using the ‘B’ model or other systems. This risk. CT. causing a higher risk of complications due to its lower selectivity (fig 2). guided by MRI. Those who claim that a LINAC systems are just as effective as a Gamma Knife are correct. the absence of radiation source movement together with excellent calibration and quality assurance. PET and DSA images that can be fused together. the Gamma Knife ‘C’ is by far the most accurate and selective radiosurgery machine as yet developed. Results depend on planning accuracy as well as machine accuracy. the normal tissue complication probability (NTCP) has been shown to be 2-4 times higher using a LINAC (1). by concentrating many patients in one unit.control of hormonal and electrical dysfunction and thrombosis of dysplastic vessels. All over the world LINAC radiosurgery centers treat fewer patients per centre – and often without neurosurgical anatomical expertise. An even higher accuracy and selectivity has been achieved with the new model ‘C’ Gamma Knife by using many more small (4mm) isocentres combined with an automatic positioning system controlled by computer which rapidly changes the patient’s position between each treatment isocentre. The problem is that the LINAC is also effective on the surrounding tissues outside the target. develop more experience.5mm.2 Treatment plan with Gamma Knife Radiosurgery is potentially dangerous if improperly used. Fig 2. Multiple target isocentres are used to create a treatment plan in three dimensions that exactly fits the lesion shape with insignificant radiation to normal tissue. Because of the fine collimation of the rays. The guaranteed machine accuracy is better than 0. Gamma Knife centers. all without the risks of open surgery. it matters a great deal elsewhere. the accuracy of engineering and automatic positioning system. A stereotactic frame is attached to the patient and the lesion target is located. The size of the point target is adjusted by changing collimator helmets. Gamma Knife versus LINAC All machines giving a similar defined radiation dose to a target should have the same effect at the target.
Fractionation The definition of radiosurgery.Consequently they have less experience. Conditions treatable The various diseases and disorders that have been effectively treated by Gamma Knife radiosurgery are listed in Table 1 and the frequency of occurrence shown diagrammatically in pie charts in Figure 3. In consequence most established LINAC units are resorting to stereotactic fractionated radiotherapy (SRT) to try to reduce the complication rate. produces not only more complications but also worse tumour control. As noted above. The equivalent quoted accuracy of LINAC is 2. Shaw et al.0mm. (2) have documented a 2. from the first use of the word by Lars Leksell in 1951. The source of information is the Leksell Gamma Knife Society. combined with a less accurate machine. Treatment using both systems can be repeated as often as required as long as the patient can tolerate the frame on the head. In fact it is exactly the same in practice as SRT using LINAC. This has the potential disadvantage of a lower long-term control rate in benign lesions as well as being a longer and more complex therapy. then treatment can be given to two or more areas at intervals ranging from one day to several months.84 times greater risk of local tumour progression after LINAC treatment as compared with Gamma Knife.5mm for the Gamma Knife. This is especially appropriate for AVM’s. usually 0. In reality it is better than this.3mm.5cm in diameter and the risk of complications becomes greater. has always been a single dose therapy. In reality it is often worse than this and deteriorates over time due to wear in the rotation bearings as the machine gets older. There is another form of fractionation that is really multiple single doses – fractionation in space. The Gamma Knife has been criticized as being unable to deliver stereotactic fractionated radiotherapy in situations where it may be appropriate such as malignant lesions in the brain stem. the guaranteed accuracy of isocentre location is to within 0. which monitors Gamma Knife activity and performance all over the world. Where a lesion is larger than 3-3. Fractionation in time is therefore not radiosurgery but radiotherapy. This. Figure 3 Functional 5% Vascular 20% Malignant tumour 36% Benign tumour 39% . certainly several days.
7% and in grade 2 was 87. When multiple (von Hippel Lindau disease). excision is often impossible. It may be possible to improve on this figure by using PET to target the active tumour. For lesions that cannot be controlled by surgery (fig. pilocytic astrocytomas all of whom have been controlled by radiosurgery. Figure 4. and therefore growing. survival is strongly related to RTOG grading but it seems that poor prognosis patients (RTOG grades III-V) have more to gain than RTOG grades I-II (6). Supplementary local boost radiation using brachytherapy has been used with good effect (4) but the open stereotactic procedure has a risk of about 1% for each target. Haemangioblastoma Haemangioblastoma is relatively easy to excise when single and associated with a cyst. L-methyl (11C) methionine PET has been shown to correlate better to active tumour than CT or MRI enhancement (7) and we hope to report on the value of this targeting method soon. We have personal experience of a number of children with recurrent. . even though advanced imaging techniques often reveal a well-defined tumour margin. Gamma Knife radiosurgery can be delivered with better conformity than brachytherapy and without the risks of implantation. A review of this technique has reported median survival in glioblastoma (RTOG grade 3) of 116 weeks (6). Gamma Knife has been used with good effect. As is well known. In such cases Gamma Knife has been used and the result. 4). in small series.PRIMARY BRAIN TUMOURS Low grade astrocytomas Total resection of grade 1 and 2 gliomas is usually dangerous or impossible. However one of the best median survival rates in glioblastoma (110 weeks) was recorded in cases treated by thermo-brachytherapy (5). In a recent series (3) the control rate in grade 1 was 91.2%. Pineal region astrocytoma before and after radiosurgery High grade astrocytomas Survival in patients with malignant glioma increases as the dose of radiation increases but the dose is limited by the risk of radionecrosis of surrounding brain. has been control in almost every case.
Since radiosurgery is more cost effective. have shown that Gamma Knife treatment of single metastases (fig. The remaining indications for WBRT are multiple tumours (>10-15) or miliary lesions and CSF seeding. however. It is not clear how much benefit WBRT has in preventing new metastases since these may develop by new spread after treatment has finished. Several studies. 80% 3 year survival has been achieved in cases where the extracranial disease has been controlled (11). Gamma Knife treatment can control >90% of metastatic brain tumours and complications. In a comparison of Gamma Knife treatment with WBRT the quantity and quality of survival was better with Gamma Knife (12). Up to 50% 0f all patients with malignancies will develop brain metastases and. 5) can produce tumour control and survival as good as surgery plus WBRT (8). Accordingly the present recommendation is to repeat Gamma Knife surgery as necessary and avoid all WBRT.5cm) diameter single lesion especially in the posterior fossa where any temporary oedema due to radiation would have serious results.METASTASES Figure 5. usually transient swelling after about 9 months which is controllable by steroids. and 10 months after treatment. In the past. it would seem that the only indications for surgery are rapid neurological deterioration due to mass effect and the large (>3. . In this way patients will not die from the brain metastases and prognosis depends only on the extracranial disease. surgical excision of accessible metastatic tumours combined with whole brain radiotherapy (WBRT) was thought to be the treatment of choice for single metastases. more than half of these will die from progressive neurological disease. occur in 5-10% (10). the chance of local recurrence is less than after surgical removal and control does not depend on the histological diagnosis. easier for the patient and has a much lower complication rate. Moreover the results for Gamma Knife are the same for multiple metastases as for a single lesion (9). after radiotherapy alone. Metastasis before.
not all patients can be operated by a Samii. The results reported contemporaneously (16. which is safer than attempts at total removal in all but the most experienced surgical hands. the Gamma Knife treatment also has a much lower incidence than microsurgery of the minor complications and disabilities that are usually not discussed but are common after open operation (18). 80% adequate facial nerve function and 6-30% hearing preservation (14. Except for having 0% mortality. microsurgery 130 days). It is clear that. .ACOUSTIC AND OTHER NEUROMAS Pre 6 months post 2 years post Figure 6. For example. microsurgeons have reduced the mortality and morbidity of acoustic neuroma surgery. are 90% tumour control (10% recurrence or death). using a marginal dose of 12Gy. Gamma Knife surgery (fig. 7) together with 96% control of tumour growth. 6) is the treatment of choice. In addition there is 1% or more mortality even in centers of excellence (14). The typical response of an acoustic neuroma to Gamma Knife treatment. At the same time the results from using highly conformal and selective. For larger lesions (>3cm) fractionation in space may be chosen. are of 100% normal facial function and 59-70% hearing preservation (fig. or subtotal removal followed by interval radiosurgery for the remnants. microsurgery 23 days). Due to great improvements in surgical technique and the introduction of cranial nerve monitoring.17). especially in the elderly. microsurgery 39%). hospital stay (GK 3 days. proportion keeping the same job (GK 100%. At the time of publication (1997) this was equal to the results from the ‘B’ series Gamma Knife (90% facial function and 50% hearing preservation).15). for smaller acoustic neuromas. However. The same comments apply in principle to all other intracranial neuromas. Samii (13) has reported 97% tumour control with 93% normal facial movement (Grade I-II) and 47% hearing preservation. microsurgery 56%) (17). minor neurological or functional deterioration (GK 9%. unfortunately. including those from the American Acoustic Neuroma Registry. multiple isodose Gamma knife treatment with the ‘C’ series machine have improved. time away from work (GK 7 days. Average results.
The mortality and morbidity of total surgical removal of meningiomas of the skull base and venous sinuses is still unacceptably high. A ten year .3 cm 3 . Illustration of the dose plan for an infiltrating meningioma of the cavernous sinus showing conformal treatment (yellow line) and that even low doses (10Gy green line) can be designed to avoid the optic chiasm (blue line). Gamma Knife therapy (fig. The percentage risk of cranial neuropathy following Gamma Knife depends on the size of the acoustic neuroma but in all cases is significantly less than the risk after microsurgery Risk of Neuropathy 70 60 50 40 30 20 10 0 < 1 cm 1 .2 cm 2 . with two thirds of the tumours becoming smaller (19. Many surgeons elect to perform a subtotal removal in which case recurrence during the patient’s lifetime is at least 55%.20).8) has been shown to control 96-99% of meningiomas less than 3cm diameter. This control is maintained over the long term.4 cm Surgery VII VIII V MENINGIOMAS Figure 8.Figure 7. Average morbidity (usually transient cranial nerve palsies) is 2%.
If the tumour is very close to the optic nerve then a cushion of fat. . 9) is used most often when surgery has failed. Non-secretory adenomas respond best.24. Also some patients. which would have used the inferior. Samii and Dolenc all agreed with this strategy. at present. It follows that Gamma Knife treatment (fig. showed 93.26). Pituitary adenoma before and 54 months after treatment Surgical removal of pituitary adenomas is. Among secretory microadenomas. as noted above. are better tolerated by the patient and complications should be minimal. shrinkage occurs in 65-80% (25). especially those with Cushings disease have a high operative risk. PITUITARY TUMOURS Adenomas Figure 9. less conformal techniques of the ‘U’ and ‘B’ series gamma knives.1% tumour control (21). such as transnasal endoscopic or endoscopically assisted approaches. However total removal of macroadenomas is almost impossible and hormonal control of functioning microadenomas by surgery is reported to be 23-77% (23). This allows safer and more effective radiosurgery later (the same applies to pituitary tumours). the treatment of first choice because it is effective immediately. Tumour growth control rate is 92%. It is no longer acceptable to damage the patient by attempting complete removal of meningiomas. Al Mefty suggested waiting until the residual tumour actually shows signs of growth since. Attempts at second operation are much more difficult and dangerous. During a recent EANS debate (22) the notable experts Al Mefty. Teflon or other material should be inserted to create a space between the tumour and the nerve.follow up study. The new minimally invasive techniques. growth hormone and ACTH secretion responds best (60-80%) with a lesser effect on prolactin (40%) (25). the tumour may remain dormant. Elective surgical policy should be primary gamma knife treatment of tumours less than 3cm diameter (except those on the convexity dural surface) and partial removal followed by Gamma Knife treatment for larger tumours. There is therefore a high incidence of failure or recurrence. Even in these cases normalization of hormone function can be achieved in 35-95% depending on diagnosis (23.
radiosurgery. There is also a late incidence of hypopituitarism of up to 20% (25). but larger groups and longer follow up are needed for evaluation of results. For these reasons. Use of the Gamma Knife alone has produced an 87% tumour control rate in 31 patients observed for 1-7 years (30). The only hope for cure is total surgical removal at the first operation. The spectrum includes chordoma. glomus tumour. Better results have been obtained in recent years since it was realized that treatment with bromocriptine and somatostatin protects against the effects of radiosurgery.Normalisation of growth hormone in 96% of cases at 2 years has recently been reported (26). The majority of cases require management in other ways however and Gamma Knife is one of the most effective. Radiosurgery often needs to be combined with stereotactic cyst aspiration and/or installation of Yttrium (31) or bleomycin (32). Treatment with such drugs must be stopped before using the Gamma Knife. With more experience of dose calculation to achieve more curative and rapid effects without damage to functioning pituitary tissue. is only possible in about 10% of cases and the recurrence rate even after ‘total’ removal is 19% ( 28). esthesioneuroblastoma and metastases. In these cases there is greater danger of radiation damage to the optic chiasm and to any residual pituitary function. but in children often causes impaired growth with mental and sexual impairment. It is better therefore to proceed straight to Gamma Knife and avoid radiotherapy. Such multimodality approach requires a team with experience of microsurgery. Comparison of Gamma Knife with conventional radiotherapy (27) shows that Gamma Knife works faster and more effectively with less risk of complications such as hypopituitarism or optic nerve damage. paranasal sinus carcinoma. Conventional fractionated radiotherapy improves the ten year survival rates from 40% to 75% (29). patients need lifetime follow up. Radiosurgery has a continuing effect on hormonal control even beyond 4-5 years and long delayed success is now recognized. OTHER SKULL BASE TUMOURS Tumours that infiltrate the skull base are often even more difficult to manage surgically than meningiomas. Craniopharyngiomas Craniopharyngiomas continue to be a major surgical problem. Chiasmal compression will continue to require surgical intervention. . chondrosarcoma. Such surgery has a high mortality and morbidity. Management of this condition is very complex. En bloc excision is potentially curative and so must be considered where possible. juvenile angiofibroma. it is likely that Gamma Knife will replace surgery as primary treatment for microadenomas. stereotaxy and radiotherapy. haemangiopericytoma. Gamma Knife has more often been used for recurrence after failure of conventional fractionated radiation.
Ablation of the whole area of amygdala and hippocampus requires a large radiation dose and risks a local radiation reaction. These imaging methods allow stereotactic targeting of foci and the role of the Gamma Knife is likely to become more important. The results will be published shortly. FUNCTIONAL DISORDERS Epilepsy In the series of patients with AVM treated at Karolinska by Gamma Knife it was observed that 52 out of 59 cases with epilepsy were cured of their fits even though the AVM was not always completely obliterated. This led to the concept that radiosurgery may modify epileptogenic activity and attempts were made to ablate the epileptic focus in other patients where it could be defined. Regis et al (35) performed amydalohippocampectomy with the Gamma Knife and after this 81% of patients were seizure free at 2 years or more follow up. seem to respond very well. Chordoma and chondrosarcoma. where surgical resection is usually complex with many complications and recurrence is common. The lesion produced in the fifth nerve (left) and the 4mm collimator plan used to produce it (right). Metastases respond as expected and described above. with satisfactory results and reduced complications. Treatment is worth considering but large series are not available yet to predict success. functional MRI and PET to localize epileptic activity is likely to increase the proportion of patients found to have focal epilepsy. Regis has concentrated recently on lesioning the parahippocampal gyrus. Trigeminal Neuralgia Figure 10. Glomus jugulare tumours. . The largest experience is in mesial temporal sclerosis.Haemangiopericytoma responds very rapidly and usually disappears. however it has a tendency for late recurrence and patients must be followed. Other conditions have been the subject of case reports and small series. although ‘radioresistant’. Research using magnetoencephalography. have been controlled in 73% of cases (33). 100% control with 64% improvement of symptoms has been reported (34).
but it seems unreasonable to withhold the benefit of medial thalamotomy in cases of cancer pain where all else has failed. The use of stereotactic deep brain stimulation has fewer cerebral complications but more practical problems associated with the implanted electrode and stimulator. Giving a second dose to failed cases resulted in an overall cure rate of 98% but all of those given a second dose suffered dysaesthesia (38). Hypophysectomy is also useful in bone pain from Ca breast metastases. as a more appropriate target with a cure rate of 83% and dysaesthesia 4% (39). Post-herpetic trigeminal neuralgia. Chronic pain In general destructive lesions for the treatment of pain are to be discouraged. A multicentre study (36) showed 58% pain free. This is due to the realization that many patients become refractory to levodopa after long-term use. . Parkinson’s disease and other dyskinesias There has been renewed interest in surgical intervention to treat Parkinson’s disease. 65% of unilateral pain cases are effectively controlled in this way. If the radiation dose is increased or repeated the cure rate is much higher but so is the risk of mild dysaesthesia. An even more recent study has identified the plexus triangularis. In a series of 158 gamma thalamotomies for tremor the cure rate was 88% with results maintained at 4 years follow up (41). Since the overall results of Gamma Knife radiosurgery can be better than other techniques it is likely to become progressively more popular. Two patients (1.3%) had a mild lesion induced neurological deficit. combined with the occurrence of dyskinetic movements associated with Sinemet. The Gamma Knife was originally designed and intended as an instrument for thalamotomy. The classical approach to stereotactic neurosurgery for Parkinson’s disease has been to perform lesions by placing an electrode in the appropriate target and heating it by radiofrequency current. The effectiveness of Gamma Knife treatment is the same as a traditional open stereotactic procedure but with much lower complications. Both thalamotomy and anterior cingulotomy can benefit chronic pain of non-malignant aetiology but the indications and results are not yet clarified.A Gamma Knife lesion at the root entry zone of the fifth nerve (fig. 5-8mm from the brain stem. The control of dyskinesia is delayed for 6-18 months from treatment. 36% improved and 6% unchanged. which does not respond to other surgical treatment (except brain stem DREZ lesions). but only recently have large series with adequate follow up been reported. 10) offers a high chance of improvement in drug resistant cases and avoids most of the morbidity of invasive surgical approaches. The main complications are intracerebral haemorrhage and neurological damage due to misplaced lesions. The risk of facial dysaesthesia is 2-4%. A recent study with a 90Gy dose gave a cure rate of 73% but a 16% incidence of dysaesthesia (37). From the same center the relief of Sinemet induced dyskinesia by pallidotomy was 85% and pallidotomy also improved two thirds of patients with rigidity and bradykinesia. has been shown to respond to the gamma knife in 44% of cases (40).
VASCULAR CONDITIONS Arteriovenous malformations Figure 10. the risk of radiation damage and the risk of haemorrhage before occlusion occurs. This large experience has made it possible to develop computer programs to predict the results of treatment (44) and in particular the probability of total occlusion. There has been a very long experience of Gamma Knife treatment of AVM because accurate stereotactic localization was possible from angiography before the advent of CT and MRI. A thalamic arteriovenous malformation before and two years after Gamma Knife treatment. Many studies have shown that 60% of stereotactic anterior capsulotomy procedures are successful (42) and this is in agreement with my personal experience of 60 cases of subcaudate tractotomy and anterior cingulotomy performed in Bristol (43). In the subgroup of obsessive-compulsive anxiety it is well known that limbic lesions can rehabilitate socially destroyed patients. It is therefore possible for all units to calculate the dose that has the greatest chance of success and the lowest rate of complications. The procedures are greatly underrated and a placebo controlled double blind study is currently underway in Sweden and USA using the Gamma Knife.Obsessive-compulsive neurosis An unscientific backlash against stereotactic psychosurgery has effectively halted operations in many countries but this is unjustified. The first lesion was treated in 1972. It has been suggested that a single right-sided lesion may be adequate (42). . The results should cause a change in medical and social prejudice.
These include proton irradiation. or when a residual nidus remains after other treatment. embolisation and Gamma Knife surgery. patients should be evaluated by a team experienced in microsurgery. The complication rate for radiosurgical treatment of cavernomas is unexpectedly high and this has been attributed to an amplification or radiosensitisation effect caused by the haemosiderin ring (50). The indications for microsurgery are certainly very limited now. Gamma Knife is particularly indicated when lesions are inaccessible to surgery and embolisation. . mainly compact lesions at or near the convexity of the brain in non-eloquent areas. In particular. multiple shunts or fistulas and few draining veins. Permanent complications were 5%. Cavernous angiomas (cavernomas) Cavernomas are vascular malformations with well-defined margins and a surrounding haemosiderin deposit. ORBITAL LESIONS Uveal melanoma Enucleation of the eye does not prevent metastases and there has been a suggestion that it may encourage them. Many groups have published similar results (44-46). It is also important to stress that the risk of radiosurgery is less than other methods and so it is appropriate as a primary treatment unless contraindicated. It is often necessary. It is evident that. Iodine-125 brachytherapy and Ruthenium plaque insertion all of which have practical problems and complications. Often these are asymptomatic lesions that require no therapy. which can safely tolerate a higher dose. especially in large lesions. Recurrent bleeding or other symptoms may be cured by surgical excision if they are easily accessible but frequently they are not. for example a single high flow fistula is best managed endovascularly. (48) reported 47 patients with bleeding cavernomas and noted a significant reduction in risk of bleeding from 32% per year to 9% per year. Kondziolka et al. However it is not possible to say any one treatment is dominant. Associated epilepsy is usually abolished. Total obliteration in lesions less than 3cm diameter should be 40% at one year. compact or plexiform lesions. (49) analysed 51 cases presenting either as haemorrhage or intractable epilepsy. For this reason smaller lesions. Success and risk are strongly related to total dose and lesion size. The risk of local oedema due to radionecrosis is 2-4% and the risk of rebleeding within 2 years is also 2-4%. are more effectively treated. to rely on multimodality treatment (46). 80% at 2 years and 90% at 3 years. rebleeding is inversely related to dose. but no angiographically demonstrable lesion. Two large series have established radiosurgery as the optimal therapy.Favourable factors for success of radiosurgery are lower flow. embolisation followed after 3 months by Gamma Knife (to allow time for collaterals to open) has been a productive combination. For this reason doses should be less than for AVM of the same size and the haemosiderin ring should be excluded from the treatment plan. This has led to a search for treatments that conserve the eye and vision. Smaller lesions have a higher success rate and lower complication rate. Haemorrhage was controlled in 86% and epilepsy was controlled in 64%. control the tumour growth and preserve life. Kida et al. for the best results.
Reducing the dose has allowed the same rate of control (84%) and a reduced risk of glaucoma (16%). Tumours such as haemangiomas.000 patients treated by Gamma Knife (56). Delayed complications are mainly local swelling in or around the lesion 6-9 months after treatment (ARE – adverse radiation effect). they may be immediate or delayed. As in . The incidence is 2-10% depending on the target. This is dose related and can usually be controlled easily by steroids.5mmHg (53). CONCLUSION Assuming that the target is less than about 3. There are reasons to believe that radiosurgery is less likely to induce tumours than radiotherapy but. optic sheath meningiomas and optic nerve gliomas could be treated if the option of surgery is inappropriate. up to now.5 cm. similar to frequent air travel. it has been shown that the Gamma Knife can control a large proportion of the neurosurgical pathologies that occur in the brain. Recent experience in the management of very severe glaucoma has been encouraging with the pain being controlled in all cases and the mean intra-ocular pressure dropping from 40mmHg to 22. Other orbital lesions The feasibility of treating other conditions depends on the need to preserve vision by avoiding significant doses to the lens and optic nerve. Immediate side effects are moderate headache. Radiotherapy for tinea capitis is well known to predispose to meningiomas (54) and fractionated radiotherapy for pituitary adenomas increases the risk of other local tumour formation by nine times compared with the normal population (55). The complication that worries some observers is the possibility of radiation induced tumours. is unlikely to affect the indications for Gamma Knife treatment. Over a 4 year follow up 13% developed metastases and 10% died of their disease. Very occasionally radionecrosis occurs and may require decompressive surgery. However this miniscule risk.g. there have been four cases in the over 200. However the Gamma Knife is a very powerful tool with potential complications and needs careful and experienced handling. In another series there was 92% control (52). dizziness and vomiting after vestibular schwannoma treatment).Gamma knife therapy has been used in certain centers with an opthalmological interest for over 10 years. radiotherapy or LINAC based radiosurgery. This is usually because a larger than safely tolerated dose has been given in malignant disease and is therefore expected. Because the delay to presentation may be as much as 30 years it is likely that this proportion will rise. Because it is well known that radiotherapy can cause brain tumours it has been assumed that Gamma Knife can do the same. skin hypersensitivity if the target is near the surface and acute cranial nerve disturbances (e. Initial high dose treatments were accompanied by severe side effects such as neovascular glaucoma (51). The complications that exist are mainly minor and transient. COMPLICATIONS It has been emphasized above in relation to particular lesions that the complication rate after Gamma Knife treatment is significantly less than after microneurosurgery.
especially in areas near the brain stem. Int J Radiat Oncol Biol Phys 1994. Farnan N. Int J Radiat Oncol Biol Phys 1998. Gamma knife radiosurgery for low-grade astrocytomas: results of long term follow up. quality assured. the results will inevitably be even better. Dinapoli R. 4. Interstitial radiation and hyperthermia. Kline R. A comparative survival analysis. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumours and metastases: Final report of RTOG protocol 9095. Smith V. 2. Shaw E. pp499-510. Loeffler J. Basel. 30: 591600. Kondziolka D. WB Saunders. 47: 291-298. the highly conformal ‘Leksell Gamma Plan’ and multi isodose treatment using the APS (automatic positioning system) come to be analysed in a few years time. Comparison of radiosurgery treatment modalities based on complication and control probabilities. No equivalent surgical operation can claim this. Kobayashi T.84 times greater chance of local progression of primary brain tumours and metastatic tumours after LINAC radiosurgery as compared with Gamma Knife (2). correct selection of patients and judicious. In addition Gamma Knife is more economic than both LINAC radiosurgery and microneurosurgery. The treatment mortality is zero. For benign tumours the growth control rate is similar in all radiosurgery treatments. skull base. Serago CF.59). Because the planning is more accurate. Gutin PH. Philadelphia. J Neurosurg 2000. When long term follow up of future series using the ‘C’ model. Int J Radiat Oncol Biol Phys 2000. In Berger MS. 40: 507-513. The Gliomas. 2000. 1998. Verhey L. All studies that have compared the incidence of more minor complications between Gamma Knife and microsurgery have shown a huge reduction of complications by using Gamma Knife radiosurgery (17. Karger. The overall costs of Gamma Knife in a European environment (Austria) are about 5% less than those of a dedicated LINAC (57). Rossman K. Wilson CB (eds). In practice the risk is even greater if the target is near the brain stem or skull base. Souhami L. 3. despite the fact that the majority of cases were managed using the earlier ‘U’ and ‘B’ models and with dose planning systems that were primitive by today’s standards. Stereotactic radiosurgery for glial neoplasms. . References 1. Flickinger JC. Better control of malignant tumour growth is achieved using Gamma Knife. For acoustic neuroma treatment Gamma Knife costs less than half (41%) of surgical treatment (58). Kida Y. use of equipment are of paramount importance. 93(suppl 3): 42-46. Stea B. cranial nerves and critical functional areas. Almost all of the results summarized above are better than those of alternative treatments. There are also fewer complications than when using LINAC for radiosurgery. 6.every branch of medicine. 5. the risk is less when using the Gamma Knife. Prog Neurol Surg. Studies have shown that the normal tissue complication probability (NTCP) is 2-4 times higher if a typical LINAC is used (1). Sneed PK. Gamma Knife is also significantly more cost effective than microsurgery in both Europe and USA. Mori I et al. 14: 160-174. Kittleson J et al. Gamma Knife treatment has been subjected to a more intense and comprehensive follow up than most contemporary treatment methods. Interstitial irradiation vs interstitial thermo-radiotherapy for supratentorial malignant glioma. The most important advantage is that there are fewer complications than with microsurgery. Lunsford L Dade. For the management of metastases the cost is three quarters (74%) of surgical treatment (59). There is a 2. Scott C.
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obsessive compulsive neurosis. glaucoma. trigeminal. OTHER SKULL BASE TUMOURS Chordoma. haemangioblastomas. . jugular fossa. trigeminal neuralgia. central neurocytoma. FUNCTIONAL DISORDERS Epilepsy. choroid plexus papilloma. METASTASES NEUROMAS Acoustic. dural A-V fistula. juvenile angiofibroma.TABLE 1. optic nerve glioma. high grade astrocytomas. glomus tumours. Parkinson’s disease and other dyskinesias. hormone secreting adenomas. chronic pain. cavernous angiomas. metastases. haemangiopericytoma. germinoma. lymphocytic hypophysitis. craniopharyngiomas. chondrosarcoma. ORBITAL LESIONS Uveal melanoma. pineal tumours. facial. CONDITIONS TREATABLE BY GAMMA KNIFE RADIOSURGERY PRIMARY BRAIN TUMOURS Low grade astrocytomas. esthesioneuroblastoma. sub-foveal neovascularisation. MENINGIOMAS PITUITARY TUMOURS Non-secretory adenomas. VASCULAR LESIONS Arteriovenous malformations. paranasal sinus carcinoma. orbital haemangioma. haemangioendothelioma. optic sheath meningioma.
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