Carcinomatous meningitis: are surgeryand gamma knife radiosurgery treatment risk factors?

OBJECT: The aim of this study was to assess the effects of the gamma knife automatic positioning system (APS) on the treatment of patients, particularly effects of this system on the treatment of patients with vestibular schwannomas (VSs), with a view to reducing loss of hearing.

METHODS

The dose delivery with an increased number of shots was checked with GAFChromic Film for various numbers of shots (one to 129). The results in the first 549 patients were recorded. In addition a series of 59 patients with VSs treated with 13 Gy to the 65% isodose is presented. The authors have termed this the "13 on 65" concept. The film dosimetry showed that a large number of small shots did not materially affect the dose and dose distribution produced by gamma knife treatment. The APS was used alone in 72% of arteriovenous malformations, 71% of meningiomas, 94% of VSs, and 84% of pituitary adenomas. Metastatic tumors were accessible in a pure APS mode in 59% of all cases, glioma in 58%, and uveal melanoma in 10% of the cases. Thus two thirds of patients could be treated using APS alone. It was possible to use the APS and manual systems together for complex or very eccentrically placed targets. The APS resulted in the use of a larger number of isocenters. After a mean follow-up period of 15 months, the results in patients with the VSs in whom 13 Gy was delivered to the 65% isodose were similar to those in patients treated with the more conventional 50% margin isodose. There was no change in the incidence of hearing loss within the study period, and the incidence of trigeminal and facial neuropathies remained unchanged after treatment as well.

CONCLUSIONS

The APS encourages the design of more conformal dose plans. The greater use of smaller collimators results in a steeper dose gradient with a smaller amount of radiation outside the target volume. Because the APS is able to apply a large number of smaller isocenters in an acceptable time, the number of isocenters used is increased. An increased number of isocenters can also be used to reduce the maximum radiation dose and increase the homogeneity in a given dose plan.