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Gamma knife in posterior third ventricular tumors
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Gamma knife in posterior third ventricular tumors

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  • 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.
    • Posterior third ventricular tumors(PTVT)
    • diverse histology
      • Third ventricle,
      • Velum interpositum,
      • Thalamus,
      • Midbrain,
      • Tentorium,
      • Splenium,
      • Quadrigeminal cistern or
      • posterior vasculature
    12/18/2009 NSI-2009
  • 3.
    • Benign
      • Meningiomas
      • Ependymomas
      • Teratomas
      • Pinealocytomas
    • Malignant
      • Germ cell tumors
      • Non-Germ cell tumors
      • Metstasis
    12/18/2009 NSI-2009
  • 4.
    • CSF diversion
    • Microneurosurgery
    • Radiation therapy
    • Chemotherapy
    • Radiosurgery
    12/18/2009 NSI-2009
  • 5.
    • Microneurosurgery- complex anatomy vasculature, critical structures limit complete resection
    • Radiation therapy- cognitive impairment, radiation toxicity, hormonal imbalances
    • Chemotherapy associated toxicity
    12/18/2009 NSI-2009
  • 6.
    • 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
    12/18/2009 NSI-2009
  • 7.
    • Retrospective Study
    • July 97-2009
    • Study conducted at AIIMS
    • Data collected from hospital records, patient files.
    12/18/2009 NSI-2009
  • 8.
    • Inclusion criteria
    • Tumors in and around the posterior third ventricular region who received Gamma-knife radio-surgery at our institute were included in the study
    12/18/2009 NSI-2009
  • 9.
    • Clinical examination
    • Biopsy reviewed
    12/18/2009 NSI-2009
  • 10.
    • Primary GK
      • GK based on Imaging +/- tumor markers
      • Biopsy +GK
    • Secondary GK
      • GK following radical surgery
    12/18/2009 NSI-2009
  • 11.
    • GK was done on Leksell B system
    • Parameters assessed
      • Tumor volume
      • Marginal dose
    • Follow up at 6 monthly interval
      • CEMRI
        • MRI screening spine + CSF markers (when required)
    12/18/2009 NSI-2009
  • 12.
    • Neuroradiologist reviewed any change in size by visual and manual measurement
    • Tumor control- same or decrease in size as compared to at time of GK
    12/18/2009 NSI-2009
  • 13.
    • Total -17 patients
    • Age range 14-74 years (mean-36.8 years)
    • M:F 7:10
    • Follow up 4-75 months (mean-31.23 months)
      • 1 patient lost to follow up.
    12/18/2009 NSI-2009
  • 14. 12/18/2009 NSI-2009
  • 15.
    • Tumor volume - 1-16.8 cm3 (mean-6.06cm3)
    • Radiation dose - 11-25 Gy (mean-15.35Gy)
    • Tumor volume coverage - 88%-94% (mean-91%)
    • 3/17 patients underwent radiation or chemotherapy as adjuvant treatment.
    12/18/2009 NSI-2009
  • 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. 12/18/2009 NSI-2009
  • 18.
    • Primary GK
    • Beningn
    • - Meningioma (4)
    • - Pinealocytoma (1)
    • - Glioma (1)
    • Malignant
    • - Pinealoblastoma (2)
    • - Metastasis ( 1)
    12/18/2009 NSI-2009
  • 19.
    • Seconadry GK
    • Beningn
    • - Meningioma (4)
    • -Glioma (2)
    • Malignant
    • - Pinealoblastoma (1)
    • -PNET (1)
    12/18/2009 NSI-2009
  • 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. 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.
    • PRIMARY GK
    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. 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. Pinealocytoma at GK Pinealocytoma post 24 months GK 12/18/2009 NSI-2009
  • 25. Meningioma at GK Meningioma after 75 months GK 12/18/2009 NSI-2009
  • 26. Pinealoblastoma Pre- Operative 12/18/2009 NSI-2009
  • 27. At GK planning Pinealoblastoma 9 month after GK 12/18/2009 NSI-2009
  • 28.
    • Decrease in size - 7/14(50%) patients
    • Same size - 6/14 (42.8%) patients
    • Good tumor control - 13/14(92.8%)
    • (At an average follow up of 31.23.2 months)
    12/18/2009 NSI-2009
  • 29.
    • Primary GK in beningn disease
    • All patients had 100 % tumor control rates at 27 months
    • Primary GK in malignant tumors
        • Pinealoblastoma patients had good tumor control at 24months and 27 months post GK
        • Metastasis of a carcinoma breast died at 7 months follow up.
    • ( Pinealoblastomas have mean survival rate of 29 months with surgery and adjuvant chemo/radiotherapy)
    • .
    12/18/2009 NSI-2009
  • 30.
    • 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
    • Stereotactic gamma radiosurgery for pineal and related tumors. Journal of neurooncology 2001; 54:301-309 .
    12/18/2009 NSI-2009
  • 31.
    • L Manera et al observed effective tumor control in germinomas, pinealoblastomas with recovery o f normal CSF pathways in 7 days of surgery.
    • Pineal region tumors: The role of stereotactic radiosurgery. Stereotactic and functional Neurosurg 1996;66(suppl 1):164-173
    12/18/2009 NSI-2009
  • 32.
    • GK surgery valuable and safe alternative as a Primary treatment for posterior third ventricular tumors
    • Negligible morbidity in the medium term
    • Good local tumor control in even malignant tumors
    12/18/2009 NSI-2009