Radiotherapy of

Parasellar Tumours
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 Introduction
• Treating parasellar tumors is
complex, typically requiring a
multimodal approach involving
The parasellar region, situated around the sella surgery, radiation therapy, and
medical treatment.
turcica, contains crucial neurovascular structures.
• Surgical removal is often the initial
step but can be challenging due to the
proximity of critical structures,
Key components  the cavernous sinuses, sphenoid leading to high surgical risks.
sinus, and suprasellar cistern structures. • Radiation therapy is commonly
used as an adjuvant or primary
treatment, especially when surgery is
not feasible.

provide an overview of different radiation techniques for parasellar tumors, with an

emphasis on non-adenomatous tumors, discussing established and newer approaches and their associated
outcomes and morbidity.
Methods and Materials
Literature Search

Conducted in MEDLINE PubMed to evaluate patients with benign and malignant parasellar
tumors.

Keyword Search

Utilized keywords such as "parasellar," "radiation therapy," "radiosurgery," "fractionated

stereotactic RT (FSRT)," and "protons" in combination.

Tumor Definitions

Additional searches included definitions of various parasellar tumors, such as

craniopharyngioma, chordoma/chondrosarcoma, schwannoma, dermoid and epidermoid
tumors, hamartomas, lipomas, Rathke's cyst, hemangiopericytomas, optic or hypothalamic
gliomas, germ cell tumors, primary lymphomas, and brain metastases.

Focus on Research Type

Emphasized randomized, prospective, and retrospective trials for inclusion in the review.
Methods and Materials
Exclusion Criteria

• non-English abstracts
• not available through PubMed
• involved case studies with fewer than 10 patients
(except for rare tumors), or were duplicated
publications.

Inclusion Criteria

• Relevant results from the literature research were

incorporated into the study as appropriate.
 Radiation Techniques
Evolution of Radiation Techniques

Concerns about long-term Transition from CRT to 3-D

Conventional radiation therapy toxicity: hypopituitarism, optic conformal and stereotactic
(CRT) for parasellar tumors,  neuropathy, neurocognitive techniques (SRS and FSRT)
45–60 Gy in 25–33 fractions. function impairment, cranial with improved precision and
nerve deficits. reduced normal brain irradiation.

Stereotactic Radiosurgery (SRS)

• Delivery of high radiation doses to small targets.
• Used for residual, recurrent, or primary treatment when surgery is not possible.
• Administered in a single fraction or hypofractionated (2-5 fractions).
• Common techniques: Gamma Knife (GK) and LINAC-based systems.
• GK: Utilizes cobalt-60 sources, often with a stereotactic head frame (GK Icon offers frameless options).
• LINAC: Employs multileaf collimators for precise beam shaping, with immobilization using masks.
 Radiation Techniques
CyberKnife Particle Radiation (Protons)

• Combines a mobile LINAC mounted on a robotic arm
with image guidance.
• Uses thermoplastic masks for patient fixation.
• Delivers treatment as single or multi-fraction SRS with
up to 200 overlapping beams.
• Corrects positioning errors with digital X-ray image
guidance.
• High dose conformality, better normal tissue sparing,
lower integral dose, and no exit dose beyond the target.
• Proton therapy applied successfully in various cancers,
including some parasellar tumors.
• Doses up to 76–78 Gy used in conventional
fractionation.

No comparative studies
Debate continues regarding dose
demonstrating clinical superiority
delivery and distribution for each
among GK, CyberKnife, and
technique.
LINAC.
 Neuroanatomical Considerations and
Risk of Radiation-Induced Toxicity

Structures at Risk of Radiation-Induced Toxicity:

• Cranial nerves, cavernous sinus, and the pituitary gland are vulnerable structures during radiation
treatment for parasellar tumors.

Factors Influencing Risk:

• Risk depends on total dose, dose per fraction, number of fractions, and volume of normal tissue
receiving high doses.
• Clinical risk estimates for skull base structures vary (in the table 1)
• Risk of radiation-induced optic neuropathy is low for doses <8–10 Gy to the optic pathway.
• Low risk for maximum doses of 10–12 Gy to small optic pathway portions.
• Similar low risk for doses of 20 Gy in 3 fractions and 25 Gy in 5 fractions.
Treatment Decision: SRS vs. FSRT:
• Choice based on target lesion volume and proximity to sensitive structures like the optic pathway.
• FSRT preferred for tumors larger than 3 cm or involving the optic pathways.

Tolerance of Other Nerves:

• Oculomotor and trigeminal nerves can tolerate higher doses.
• Doses up to 40 Gy relatively safe for nerves in the parasellar region.
• Radiation-induced toxicity <4% observed for doses up to 18–20 Gy to the cavernous sinus nerves.

Hormonal Pituitary Deficits:

• Main side effect of radiation therapy, especially in sellar-involved tumors.
• Keep mean radiation doses to the pituitary gland under 15 Gy and 7–10 Gy for the stalk to avoid
hypopituitarism.
• Multisession SRS considered for large tumors near the optic apparatus.
Results of Radiation Treatments in Parasellar Tumours

Meningiomas:

• Parasellar meningiomas often require radiation therapy

(FSRT or SRS) after incomplete surgical resection.
• Postoperative CRT with 50–55 Gy yields 79-95% local
control at 5 years.
• FSRT and IMRT show comparable local control rates
(91% at 10 years).
• Hypopituitarism occurs in 5-15%, and optic apparatus
injury in 0-3% of irradiated patients.
• Proton beam RT achieves 90-96% local control at 5 years.
Results of Radiation Treatments in Parasellar Tumours

Craniopharyngioma:

• Surgery is the main treatment; radiation is used after subtotal

resection or recurrence.
• Subtotal resection followed by RT provides better long-term control
rates.
• Postoperative RT improves survival compared to incomplete surgery
alone.
• Radiation can be given immediately post-surgery or at regrowth.
• Late complications include hypopituitarism (20-60%) and optic
neuropathy (2-8%).
Results of Radiation Treatments in Parasellar Tumours

Chordoma and Chondrosarcoma:

• High cumulative fractionated radiation doses (up to 70-75 Gy) are

needed for chordomas.
• IMRT and FSRT offer better outcomes with higher doses and
reduced toxicity.
• Proton beam RT (63-83 Gy) is becoming the standard for residual or
recurrent chordomas.
• Chondrosarcomas require radiation due to high recurrence rates.
• Proton radiation shows excellent 5-year overall survival and local
control rates (>90%).
Results of Radiation Treatments in Parasellar Tumours

Rare Parasellar Tumors:

•  schwannomas, epidermoids, dermoids, hamartomas, lipomas,

Rathke's cyst, hemangiopericytomas, optic/hypothalamic
gliomas, germ cell tumors, primary lymphomas, and brain
metastases.
• Fractionated RT (50-60 Gy) is used for infiltrative aggressive
tumors.
• SRS is employed for small-to-moderate benign lesions or
recurrent tumors.
• Data on rare parasellar tumors are limited.
 Conclusion
Radiation therapy (RT) is
effective for incomplete
resected parasellar tumors or
those at inaccessible surgical
sites.
Proton therapy recommended
Reported radiation toxicity is
generally acceptable.
Fractionated RT and
stereotactic radiosurgery Fractionated RT preferred for
(SRS) offer similar local large infiltrative tumors; SRS
control, chosen based on for smaller lesions.
tumor volume and location.
Molecular research may help
for large aggressive tumors
identify patients who benefit
like chordomas and
from adjuvant RT.
chondrosarcomas.
 Critical
Appraisal
Patient/Population
• The results of the literature research were
used and included if appropriate  Patients
with parasellar tumors (including meningiomas,
craniopharyngiomas, chordomas,
chondrosarcomas, and other rare parasellar
tumors).
PICO
Comparison
• Comparison of different radiation techniques
and modalities, including conventional
radiation therapy (CRT), stereotactic
radiosurgery (SRS), fractionated stereotactic
radiotherapy (FSRT), and proton therapy
Intervention
• The search focused on randomized,
prospective and retrospective trials 
Radiation therapy (RT) as a treatment modality
Outcome
• Evaluation of treatment efficacy in terms of local
control of tumors.
• Assessment of radiation-induced toxicity and
complications & Analysis of long-term survival rates.
• Investigation of the role of radiation therapy in
treating parasellar tumors and its potential benefits in
different tumor types.
• Yes, It provides details on radiation
Yes, Understanding the various radiation therapy
therapy techniques and their
effectiveness. Importance
techniques and their outcomes for different types
of parasellar tumors is important
 this study provided the potential risks and
• The information presented appears
benefits of radiation therapy for parasellar
to be scientifically valid. It mentions tumors
specific studies, radiation doses,  crucial information for making
and treatment outcomes, which informed treatment decisions.
suggest that the content is based on
research and medical knowledge.
Validity Importance
• The references to studies and data
sources in the text contribute to its
validity by citing credible sources.

Applicability

Yes, it may be as reference in our clinical practice

Overall, this review appears to be a valid, important, and applicable source of information for
those involved in the treatment and research of parasellar tumors and radiation therapy.
Critical Appraisal
of a Meta-analysis
or Systematic
Review
Thank You