Gamma knife in posterior third ventricular tumors

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Gamma knife in posterior third ventricular tumors

  1. 1. Vikas Naik, Deepak Agrawal, SS Kale, MS Sharma, BS Sharma, AK Mahapatra Department of Neurosurgery & Gamma-Knife surgery, All India Institute of Medical Sciences, New Delhi
  2. 2. <ul><li>Posterior third ventricular tumors(PTVT) </li></ul><ul><li>diverse histology </li></ul><ul><ul><li>Third ventricle, </li></ul></ul><ul><ul><li>Velum interpositum, </li></ul></ul><ul><ul><li>Thalamus, </li></ul></ul><ul><ul><li>Midbrain, </li></ul></ul><ul><ul><li>Tentorium, </li></ul></ul><ul><ul><li>Splenium, </li></ul></ul><ul><ul><li>Quadrigeminal cistern or </li></ul></ul><ul><ul><li>posterior vasculature </li></ul></ul>12/18/2009 NSI-2009
  3. 3. <ul><li>Benign </li></ul><ul><ul><li>Meningiomas </li></ul></ul><ul><ul><li>Ependymomas </li></ul></ul><ul><ul><li>Teratomas </li></ul></ul><ul><ul><li>Pinealocytomas </li></ul></ul><ul><li>Malignant </li></ul><ul><ul><li>Germ cell tumors </li></ul></ul><ul><ul><li>Non-Germ cell tumors </li></ul></ul><ul><ul><li>Metstasis </li></ul></ul>12/18/2009 NSI-2009
  4. 4. <ul><li>CSF diversion </li></ul><ul><li>Microneurosurgery </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Radiosurgery </li></ul>12/18/2009 NSI-2009
  5. 5. <ul><li>Microneurosurgery- complex anatomy vasculature, critical structures limit complete resection </li></ul><ul><li>Radiation therapy- cognitive impairment, radiation toxicity, hormonal imbalances </li></ul><ul><li>Chemotherapy associated toxicity </li></ul>12/18/2009 NSI-2009
  6. 6. <ul><li>To evaluate the effectiveness of gamma knife (GK) surgery in posterior third ventricular tumors as a primary treatment or in conjunction with surgery and/or biopsy </li></ul>12/18/2009 NSI-2009
  7. 7. <ul><li>Retrospective Study </li></ul><ul><li>July 97-2009 </li></ul><ul><li>Study conducted at AIIMS </li></ul><ul><li>Data collected from hospital records, patient files. </li></ul>12/18/2009 NSI-2009
  8. 8. <ul><li>Inclusion criteria </li></ul><ul><li>Tumors in and around the posterior third ventricular region who received Gamma-knife radio-surgery at our institute were included in the study </li></ul>12/18/2009 NSI-2009
  9. 9. <ul><li>Clinical examination </li></ul><ul><li>Biopsy reviewed </li></ul>12/18/2009 NSI-2009
  10. 10. <ul><li>Primary GK </li></ul><ul><ul><li>GK based on Imaging +/- tumor markers </li></ul></ul><ul><ul><li>Biopsy +GK </li></ul></ul><ul><li>Secondary GK </li></ul><ul><ul><li>GK following radical surgery </li></ul></ul>12/18/2009 NSI-2009
  11. 11. <ul><li>GK was done on Leksell B system </li></ul><ul><li>Parameters assessed </li></ul><ul><ul><li>Tumor volume </li></ul></ul><ul><ul><li>Marginal dose </li></ul></ul><ul><li>Follow up at 6 monthly interval </li></ul><ul><ul><li>CEMRI </li></ul></ul><ul><ul><ul><li>MRI screening spine + CSF markers (when required) </li></ul></ul></ul>12/18/2009 NSI-2009
  12. 12. <ul><li>Neuroradiologist reviewed any change in size by visual and manual measurement </li></ul><ul><li>Tumor control- same or decrease in size as compared to at time of GK </li></ul>12/18/2009 NSI-2009
  13. 13. <ul><li>Total -17 patients </li></ul><ul><li>Age range 14-74 years (mean-36.8 years) </li></ul><ul><li>M:F 7:10 </li></ul><ul><li>Follow up 4-75 months (mean-31.23 months) </li></ul><ul><ul><li>1 patient lost to follow up. </li></ul></ul>12/18/2009 NSI-2009
  14. 14. 12/18/2009 NSI-2009
  15. 15. <ul><li>Tumor volume - 1-16.8 cm3 (mean-6.06cm3) </li></ul><ul><li>Radiation dose - 11-25 Gy (mean-15.35Gy) </li></ul><ul><li>Tumor volume coverage - 88%-94% (mean-91%) </li></ul><ul><li>3/17 patients underwent radiation or chemotherapy as adjuvant treatment. </li></ul>12/18/2009 NSI-2009
  16. 16. 12/18/2009 NSI-2009 Diagnosis Histology proven MRI based Csf diversion Adjuvant RT Adjuvant CT Meningiomas (8) 4 4 1 0 0 Pineal tumors (4) 3 1 3 1 1 Gliomas (3) 2 1 1 1 0 PNET (1) 1 0 1 0 1 Metastasis (1) 0 1 0 0 0 Total (17) 10 7 6 2 2
  17. 17. 12/18/2009 NSI-2009
  18. 18. <ul><li>Primary GK </li></ul><ul><li>Beningn </li></ul><ul><li>- Meningioma (4) </li></ul><ul><li>- Pinealocytoma (1) </li></ul><ul><li>- Glioma (1) </li></ul><ul><li>Malignant </li></ul><ul><li>- Pinealoblastoma (2) </li></ul><ul><li>- Metastasis ( 1) </li></ul>12/18/2009 NSI-2009
  19. 19. <ul><li>Seconadry GK </li></ul><ul><li>Beningn </li></ul><ul><li>- Meningioma (4) </li></ul><ul><li>-Glioma (2) </li></ul><ul><li>Malignant </li></ul><ul><li>- Pinealoblastoma (1) </li></ul><ul><li>-PNET (1) </li></ul>12/18/2009 NSI-2009
  20. 20. 12/18/2009 NSI-2009 Symptom No of patients in Primary GK No of patients in Secondary GK Percentage HEADACHE 4 4 47 ASYMPTOMATIC 4 1 29.4 VOMITING 1 2 17.6 HEMIPARESIS 1 2 17.6 DROOPING OF EYELID 1 1 11.76 SEIZURES 1 0 5.8 MEMORY IMPAIRMENT 1 0 5.8 GAIT ATAXIA 1 0 5.8 URINARY INCONTINIENCE 1 0 5.8 DIPLOPIA 1 0 5.8
  21. 21. 12/18/2009 NSI-2009 SIGNS No of patients of Primary GK No of patients of secondary GK PERCENTAGE NO DEFICITS 5 3 47 HEMIPARESIS 1 3 23.5 PAPILLOEDEMA 2 1 17.6 PARINAUDS 1 1 11.76 SEVENTH NERVE 1 1 11.76 THIRD NERVE 1 1 11.76 RECENT MEMORY 1 0 5.8 NYSTAGMUS 0 1 5.8
  22. 22. <ul><li>PRIMARY GK </li></ul>12/18/2009 NSI-2009 Diagnosis Follow up period (months) Tumor volume (cm3) Radiation iso dose (Gy) Tumor control Worsening Beningn Meningiomas 41 9.05 11.8 4/4 - Pinealocytomas 36 2.2 15 1/1 - Glioma 9 3.3 12 1/1 - Malignant Pinealoblastoma 15.5 2.05 20.75 1/2 1/2 Metastasis 7 44.3 16 - -
  23. 23. SECONDARY GK 12/18/2009 NSI-2009 Diagnosis Follow up period (months) Tumor volume (cm3) Radiation iso dose (Gy) Tumor control Worsening Beningn Meningiomas 54 12.5 12.52 4/4 - Gliomas 4 6.25 16 1/1 - Malignant Pinealoblastoma 9 1.4 24 1/1 - PNET 25 3.2 16 1/1 -
  24. 24. Pinealocytoma at GK Pinealocytoma post 24 months GK 12/18/2009 NSI-2009
  25. 25. Meningioma at GK Meningioma after 75 months GK 12/18/2009 NSI-2009
  26. 26. Pinealoblastoma Pre- Operative 12/18/2009 NSI-2009
  27. 27. At GK planning Pinealoblastoma 9 month after GK 12/18/2009 NSI-2009
  28. 28. <ul><li>Decrease in size - 7/14(50%) patients </li></ul><ul><li>Same size - 6/14 (42.8%) patients </li></ul><ul><li>Good tumor control - 13/14(92.8%) </li></ul><ul><li>(At an average follow up of 31.23.2 months) </li></ul>12/18/2009 NSI-2009
  29. 29. <ul><li>Primary GK in beningn disease </li></ul><ul><li>All patients had 100 % tumor control rates at 27 months </li></ul><ul><li>Primary GK in malignant tumors </li></ul><ul><ul><ul><li>Pinealoblastoma patients had good tumor control at 24months and 27 months post GK </li></ul></ul></ul><ul><ul><ul><li>Metastasis of a carcinoma breast died at 7 months follow up. </li></ul></ul></ul><ul><li>( Pinealoblastomas have mean survival rate of 29 months with surgery and adjuvant chemo/radiotherapy) </li></ul><ul><li>. </li></ul>12/18/2009 NSI-2009
  30. 30. <ul><li>Tatsuya Kobayashi et al studied out of 30 patients who were given radiosurgery after conventional treatment and concluded that pineocytomas, germinomas had 100% control rates, malignant germ cell tumors and pineoblastomas had 50% control rates </li></ul><ul><li>Stereotactic gamma radiosurgery for pineal and related tumors. Journal of neurooncology 2001; 54:301-309 . </li></ul>12/18/2009 NSI-2009
  31. 31. <ul><li>L Manera et al observed effective tumor control in germinomas, pinealoblastomas with recovery o f normal CSF pathways in 7 days of surgery. </li></ul><ul><li>Pineal region tumors: The role of stereotactic radiosurgery. Stereotactic and functional Neurosurg 1996;66(suppl 1):164-173 </li></ul>12/18/2009 NSI-2009
  32. 32. <ul><li>GK surgery valuable and safe alternative as a Primary treatment for posterior third ventricular tumors </li></ul><ul><li>Negligible morbidity in the medium term </li></ul><ul><li>Good local tumor control in even malignant tumors </li></ul>12/18/2009 NSI-2009

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