Masep Medical

Treatment for Intracranial Lesions for 1618 Cases

2019-08-26 11:32

Preliminary Report on MASEP Rotating Gamma System Treatment for Intracranial Lesions for 1618 Cases

Yuan Shubin, Feng Zhihuai, Wen Bin, Liang Xin, Huo Yaojun, Li Xiemei, Zhou Yanqiong, Wang Yongjun

Air Force Chengdu Hospital Gamma system Treatment Research Centre

[Outline] Objective: Exploring feasibility and effectiveness of another China-made new stereotactic radiosurgery device � MASEP Rotating Gamma System in the treatment of intracranial lesions. Approach: From August 2001 to August 2004, Air Force Chengdu Hospital Gamma system Treatment Cnetre used MASEP Rotating Gamma System to treat 1618 cases of intracranial lesions, among which, male: 839 cases, female: 779 cases, aged from 1.5 to 95 years old. Cerebrovascular: 177 (10.9%), benign tumor: 704 (43.52%), malignant tumor: 595 (36.76%), functional disease: 142 (8.79%). Treatment procedure: taking 3-D thin-layer scanning using MRI to obtain positioning images; using SuperPlan-TPS (3D-Treatment Planning System) to automatically display 3D images for lesions, pre-selected target and sensitive tissues; accurate calculation and definition of treatment parameters and dose rate according to different types and nature of lesions, and treatment scheme simulation display, assessment and modification, thus arriving to final optimal treatment scheme. Treatment dose rate: peripheral dose rate: 8~75 Gy, isodose curve: 40% ~ 55%, isocenters: 1~22. Result: follow-up with 1146 cases. Complete obturation rate for deformed blood vessel in cerebrovascular diseases: 54.8%, partial obturation rate: 28.1%; growth control rate for benign tumor: 83.3%~99.6%; growth control rate for malignant tumor: 67.5%~97.2%; symptom improvement rate for functional disease: 81.1%~87.5%. Conclusion: the result shows that effect of MASEP rotating Gamma System treatment for intracranial lesions is certain. To strictly apply to adaptable diseases and define rational treatment scheme according to different nature and volume of lesions are important measures in enhancing cure and reducing complication.

[Key words] Stereotactic radiosurgery, gamma system, deformity in cerebrovascular vessel, encephaloma functional disease

MASEP rotating Gamma System is a new type stereotactic radiosurgical device designed in China. During August 2001 to August 2004, we used MASEP rotating Gamma System to treat 1618 cases of intracranial lesions. The following is report on clinical application:

1. Data and approach

1.1 Selection of patients

? diameter of lesions less than 3 cm; ? deep lesions in brain; ? residual tumor after operation; ? residual tumor after operation; ? recurrent tumor after tumor; ? functional disease; ? patient unable to endure craniotomy

1.2 General data

Sex: male: 839 cases, female: 779 cases

Age: youngest: 1.5 years old, oldest: 95 years old, average: 43.7 � 26.8.

Sizes of lesions: smallest in diameter: 0.5 cm, biggest in diameter: 5.5 cm

Nature and types of lesions: For 1618 cases, according to CT, MRI, DSA and incretion measurement, and stereotatic biopsy or surgical pathological examination, 892 cases were confirmed through imaging and incretion measurement, 584 cases were confirmed through biopsy or surgical pathological examination, 142 cases of functional neurological diseases were confirmed through clinical symptoms, MRI, EEG, SPECT, PET and MEG. For types of lesions please refer to Table 1.

Table 1: Classification of 1618 cases
Classification of lesions
Number of cases
Percentage (%)
Number of cure (%)
Blood vessel diseases
Cerebral arteriovenous malformation (AVM)
154
87.00
9.50
Cavernous angioma (CA)
23
13.00
1.42
Subtotal
177
100.00
10.90
 
Benign tumor
Hypophyseal tumor
426
66.51
26.32
Meningoma
142
20.17
8.78
Acoustic nerve tumor
55
7.82
3.40
Craniopharingioma
42
5.97
2.60
Spinal funiculus tumor
15
2.13
0.92
Angioreticuloma
13
1.84
0.80
Trifacial sheath tumor
6
0.85
0.37
Others
5
0.71
0.30
Subtotal
704
100.0
43.52
 
Malignant tumor
Glioma
177
29.74
10.93
Metastatic tumor
308
51.77
19.03
Pinealoma
48
8.06
2.97
Nasopharynx tumor
36
6.05
2.22
Lymphoma
6
1.00
0.37
Others
20
3.36
1.24
Subtotal
595
100.0
36.76
Total no. of intracranial tumor
1299
80.31
 
 
Functional diseases
Epilepsy
86
60.57
6.48
Parkinson抯 disease
2
1.41
0.12
Trifacial neuralgia
51
35.91
2.71
Others
3
2.11
0.18
Subtotal
142
100.0
8.79
 

1.3 Treatment procedure

1.3.1 Installing positioning frame: local anesthesia, general anesthesia for children under 5

1.3.2 Scanning: proceed 3-D thin-layer scanning using MRI to obtain positioning image

1.3.3 Planning treatment: using MASEP SuperPlan 3D-TPS to interactively display and position in 3 dimensions body surface, pre-selected focus and sensitive tissues; accurately calculating and defining treatment parameters and dose rate; treatment scheme simulation, assessment and modification, and final determination on optimal treatment scheme.

1.3.4 Treatment implementation: transferring treatment scheme directly to the control system of the MASEP rotating Gamma System, adjusting 3 dimensional coordinates of the focus; adjusting gamma ray incidence angle or utilizing 3-D adjustable shields to protect eyes. For treatment dose rate used for several main lesions please refer to Table 2.

Table 2: Treatment scheme for several main lesions
Lesions
Isodose curve (%)
Peripheral dose rate (Gy)
Number of isocenters
Range
Average盨D
Range
Average盨D
Range
Average盨D
Hypophyseal tumor
40-55
44.4�8.5
8~35
18.93�6.61
1~12
3.1�2.1
Meningoma
40-50
39.8�7.9
9~26
14.2�3.3
3~9
4.8�2.6
Trifacial sheath tumor
40-50
42.0�9.6
9~16
12.5�1.9
2~7
4.0�2.1
Pinealoma
40-55
46.2�7.5
12~14
12.8�1.0
3~7
5.2�2.0
Spinal funiculus tumor
40-50
35.0�5.7
9~20
12.8�4.9
2~7
5.0�2.1
Craniopharingioma
40-50
44.7�7.1
9~12
10.2�0.7
2~11
7.0�1.5
Glioma
40-50
38.7�8.8
10~20
16.5�2.9
1~9
4.9�2.3
Metastatic tumor
40-50
43.7�8.8
12~23
16.8�3.0
1~9
2.9�2.5
AVM
40-55
46.4�6.3
15~25
20.7�2.4
1~9
3.7�2.3
CA
40-55
48.2�6.3
15~18
17.0�2.4
4~6
3.2�2.4
Epilepsy
40-50
52.4�6.2
10~35
22.4�5.6
1~6
3.4�2.8
Parkinson抯 disease
50
 
75
 
1
 
Trifacial neuralgia
50
 
40~45
 
1~2
 

1.4 Cure effect assessment standard

Cerebral blood vessel diseases:

Effective: Complete or partial obturation for deformed cerebral blood vessel

Non-effective: No obturation, lesion bleeds and needs surgical operation

Cerebral tumor:

Effective: Tumor growth controlled. This includes: disappearance, reduction in size, central necrosis and growth slow-down of tumor.

Non-effective: Tumor bleeds, increases in size needing surgical operation; recurrence of tumor.

Functional diseases:

Remarkable effective: complete control or abatement of symptom > 75%

Effective: Symptom abatement > 50%

Non-effective: symptom has no apparent abatement

1.5 Follow-up result

Periodic CT, MRI, incretion measurement or EEG of the 1618 cases after treatment was conducted. For 1146 cases (70.8%), follow-up visits in between 3~36 months (average 20.1 months) have the following results as shown in Tables 3, 4 and 5.

 

Table 3: Catamnestic result for cerebrovascular diseases
Classification
No. of treatment
No. of catamnesis
Catamnestic period (month)
Obturation
No change
Bleeding
Death
Complete (%)
Partial
(%)
AVM
154
82
6~34
45(54.8)
23(28.1)
14(17.1)
0
0
CA
23
15
6~36
6(40.0)
4(26.7)
5(33.3)
0
0
Subtotal
177
97
 
 
 
 
 
 
 
Table 4: Catamnestic result for cerebral tumor
Classification
No. of treatment
No. of catamnesis
Catamnestic period (month)
Tumor growth control (%)
No effect/no change (%)
Death (%)
Benign tumor
Hypophyseal tumor
426
295
6~36
294(99.6)
1(0.4)
0
Meningoma
142
98
12~30
82(83.7)
16(16.3)
0
Acoustic nerve tumor
55
36
6~36
30(83.3)
6(16.7)
0
Craniopharingioma
42
31
6~30
28(90.3)
3(9.7)
0
Spinal funiculus tumor
15
9
6~26
6
3
0
Angioreticuloma
13
9
6~26
5
4
0
Trifacial sheath tumor
6
4
6~24
4
0
0
Others
5
3
12~36
2
1
0
Subtotal
704
485
 
 
 
 
 
Malignant tumor
Glioma
177
126
6~36
85(67.5)
33(26.2)
8(6.3)
Metastatic tumor
308
265
3~36
250(94.3)
6(2.3)
9(3.4)
Pinealoma
48
34
3~30
28(82.4)
5(14.7)
1(2.9)
Nasopharynx tumor
36
36
3~32
35(97.2)
1(2.8)
0
Lymphoma
6
4
6~30
3
0
1
Others
20
15
3~32
11
4
0
Subtotal
595
480
 
 
 
 
²     Number of death on glioma: 8, survival period: 15-30 months, average 21.13 months.
²     Number of death on cererbral metastatic tumor: 9, survival period: 6-30 months, average 19.7 months.
 
Table 5: Catamnestic result for functional diseases
Classification
No. of treatment
No. of catamnesis
Catamnestic period (month)
Remarkable effective (%)
Effective (%)
Non-effective (%)
Death (%)
Epilepsy
86
48
12~32
20(41.6)
19(39.5)
9(18.9)
0
Parkinson抯 disease
51
32
6~34
20(62.5)
8(25.0)
4(12.5)
0
Trifacial neuralgia
2
2
6~30
0
2
0
0
Others
3
2
22~32
1
1
0
0
Subtotal
142
84
 
 
 
 
 
 
Complication:
²     For one case of hypophyseal tumor, 3 month after treatment the tumor bled, surgical operation was performed to reduce pressure to optic nerve.;
²     For one case of tumor residual for acoustic nerve tumor treatment, one month after treatment obstructive hydrencephalus happened causing intrancranial pressure increase, surgical operation was then performed.
²     For 2 cases of trifacial neuralgia, 1 and 1.5 years after treatment the symptom recurred and aggravated, craniotome was performed to decrease blood vessel pressure..
2.                 Discussion
As a consequence of development of computer technology, neurological imaging technology and other assisting technologies, in recent years, directional radiosurgery progresses in an amazing speed. Among various stereotactic directional radiosurgical devices, gamma system still dominates. MASEP rotating Gamma System optimizes design in collimator passage for radioactive rays and utilizes dynamic rotating focusing structure, thus greatly enhances defining power and regularity for peripheral of radiation field, bringing 搒harpness� to gamma system.
3~36 month catamnesis of 1146 cases shows:Complete obturation achieves 54.8% for deformed cerebral blood vessel, partial obturation achieves 28.1%. Among these cases epilepsy happened in 64 cases, 56 epilepsies were complete controlled leaving 8 cases with a decreased recurrence by 50%~80%. Growth control rate for benign tumor arrives to 83.3%~99.6%. For example, in catamnesis of 295 cases of cerebral hypophyseal tumor, tumor growth control rate is 99.6%. For 31 craniopharingioma having over 6 months catamnesis, tumor growth control rate is 90.3%. Growth control rate for malignant tumor reaches 67.5%~97.2%. Especially for metastatic tumor, gamma system treatment causes smaller wound, is safer, brings rapid effect and has high cure effect. For example for one case of lymphoma, 3 days after treatment hemiparalysis was remarkably mitigated. Its MRI showed the volume of the tumor was reduced in volume by 2 thirds from a diameter of 3.5 cm. Symptom control and relief for functional diseases reaches 72.3%~87.5%. Clinical results show MASEP Gamma System treatment for intracranial diseases has less complication and definite curing effect.
Radioactive dropsy is a frequent phenomenon after directional radiosurgery. Most of them is slight and will disappear by themselves or mitigate by using hormone or dehydrant. For serious symptom surgery might be performed when needed. With accumulation of gamma system treatment experience, all cases of our study, as a consequence of our strict application to adaptable diseases and strict control of relationship between dose rates and volume (which is key factor to reduce complication), do not bring serious intracranial radioactive dropsy that causes intracranial high pressure and needs further craniotomy.
Catamnesis shows that MASEP rotating Gamma System, like other directional radiosurgical devices, possesses the advantages of having high precision, being safe and accurate and bringing good cure and less complication.
After over 30 years of clinical application and large number of case treatment, gamma system, an advanced micro-invasion technology, has become an important assisting approach to neurosurgery. Questions such as how to enhance cure and reduce complication to make it more accomplished are still exploration for radioactive surgeons. Our up-to-date experience is: ? based on strict application to adaptable diseases and overall analysis of selected patients: for meningoma located on cerebral convex surface or glioma located in brainstem, even its diameter is less than 3 cm, gamma system should not be used. For meningoma and acoustic nerve tumor growing along the long axis of sphenoid ridge or petrous bone cone in the base of skull, dropsy reaction after treatment will be slight, even for diameter bigger than 3 cm before/after treatment. Gamma system can be used to treat these tumors; Cure for cystic tumor is not so good as for parenchymal tumor, the first should apply surgical operation beforehand; Though it抯 also malignant tumor, metastatic tumor is sensitive to treatment and its growth can be effectively controlled in short time. Therefore for diameter even equal to or bigger than 3.5 cm gamma system can be applied. Whereas for malignant glioma, cure effect is slow after treatment. Surgical operation shall be performed beforehand to cut out the tumor. ? Defining rational dose rate scheme can ensure cure and avoid or reduce complication; for example, even for very small cavernous angioma, with border dose rate bigger than 18 Gy, high dose rate curve shall still be applied to reduce dropsy reaction; For acoustic nerve tumor 11 Gy border dose rate shall be applied to control tumor growth and to protect facial nerve from damage. When treating tumors in saddle area or functional diseases and  selecting amygdaloid nucleus and globus pallidus as focuses, dose rate for optic nerve and optic chiasm shall be less than 9 Gy and less than 10 Gy for tractus optici t oavoid damage to optic passage. ? Combined treatment to enhance cure of gamma system: for example for cystic tumor stereotactic directional surgery shall be performed beforehand to pump out cystic fluid and to reduce tumor volume before treatment of gamma system; for single or less than 3 cerebral metastatic tumors, gamma system can be used in one or several separate treatment to deliver sufficient dose. For recurrent cerebral metastatic tumor overall cerebral radiation plus gamma system treatment shall be adopted to strengthen cure and prolong life; Combination of overall cerebral radiation with gamma system for treatment of nasopharynx tumor not only 搒weeps away� cancer cells invading peripheral tissues but also reach effective treatment for the center of the tumor. This approach reduces radioactive damage to normal cerebral tissues.
 
References:
1.                  Ganz J. C.; Backlund, E. O.: Thorsen, E. A.; The result of gamma system surgery in relation to size of tumor and dose. Stereotaact Funct Neurosurg 1993:61(Suppl;)23-29
2.                  Kobayash T; Tanaka D. M; Go Umnerova L. G; Craniophary gioma; Preliminary results of stereotactic radiation therapy. Radiosurgery 1995: Vol. 1:75-82
3.                  Hu Yiming, Miao Zhengjun, Dai Jiance, etc.: Gamma ray stereotactic (x, gamma system) treatment physical principle and biological basis; China Tumor Radiosurgery Journal; vol. 5 (21), 1996, p 91-96.
4.                  T. K. Helennowski; B. Potiawala. Role of gamma system in the treatment of large lesions. Stereotact Funct Neurosurg. 199:61(suppl 1):103-105
5.                  Lu Wujun, Luan Guoming: China-made rotating gamma system high dose animal test preliminary report; Functional and stereotactic neurosurgery journal; 1997: Vol 10(3):13-15.
 
/
/
Treatment for Intracranial Lesions for 1618 Cases
Copyright 2010-2019 MASEP All Rights Reserved 粤ICP备19117885号-1  Powered by 300.cn
Masep Medical Science & Technology Development (Shenzhen) Co., Ltd.
  • TOP