ROSE CASE GLOMUS TUMOR SRS

1. ROSE CASE
STEREOTAXY FOR GLOMUS JUGULARE
RADIATION ONCOLOGY
SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO
4/5/2021 1

2. WHAT IS IT?
• Glomus jugulare is a rare, slow-growing
neuroendocrine paraganglioma of the head
and neck that arises within the jugular
foramen and is localized to the jugular fossa in
the temporal bone of the skull base.
• Paragangliomas are benign and originate from
neural crest derivatives, known as the
paraganglia
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3. WHAT IS IT?
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4. CONTENT
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5. WHAT IS IT?
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6. 1st article from MAYO clinic on glomus jugularae
In the 1950s, external-beam radiation was introduced as an adjunct
to surgical removal of tumors in subtotal resections. Williams et al.
published the results from the Mayo Clinic in 1955 and noted definite
improvement at doses of 13–20 Gy delivered to the tumor over 2
weeks.

7. RADIOTHERAPEUTIC MANAGEMENT IN GLOMUS JUGLARAE
1. For fractionated RT, the dose required to treat
benign paragangliomas is 45 Gy at 1.8 Gy per
once-daily fraction.
2. Higher doses provide no improvement in local
control and result in an increase in
complications.
3. We currently treat all patients with IMRT with a
planning treatment volume expansion of 3 mm
around the gross tumor volume and use a 5- to
10-mm margin around the planning treatment
volume, depending on how well defined the
paraganglioma appears to be on the planning
CT.
4. It is key to avoid margins that are too tight and
might result in a marginal miss, particularly
considering the moderate dose that is employed
and the low probability of complications. The
optimal SRS dose, prescribed at the tumor
margin, varies between 12 and 15 Gy.

8. Let’s know
• Glomus jugulare tumors are rare, slow-growing, hypervascular tumors that arise
within the jugular foramen of the temporal bone.
• They are included in a group of tumors also referred to as chemodectomas
or nonchromaffin paragangliomas.
• Paragangloima occur at various sites and include carotid body, glomus vagale, and
glomus tympanicum tumors
• Paraganglia develop from the neural crest .They arise from Glomus cells(which is a
kind of chemoreceptor).
• Most common benign neoplasm of middle ear.
• Glomus tumor is a benign tumor, therefore lymph node metastasis is not
present.
• Hypotympanum is the usual location of Glomus Jugulare Tumor.
• It may labyrinth, petrous pyramid and mastoid
• Rule of 10: 10% familial; 10% multicentric; 10% functional (secrete catecholamines)
• Glomus jugulare tumors occur predominantly in women in the fifth and sixth
decades of life.
• Benign encapsulated, extremely vascular, very slow growing, locally invasive
• Abundant thin walled blood sinusoids with no contractile muscle coat – profuse
bleeding

9. • Glomus jugulare tumors are rare, slow-growing vascular
lesions that arise from the chief cells of the paraganglia within
the jugular bulb.
• They can be associated with the tympanic branch of the
glossopharyngeal nerve (Jacobsen nerve) or the auricular
branch of the vagus nerve (Arnold nerve) and are also
referred to as chemodectomas or nonchromaffin
paragangliomas.
• Optimal treatment of these histologically benign tumors
remains controversial. Surgery remains the treatment of
choice, but can carry high morbidity rates.
• External-beam radiation was originally used for subtotal
resections and in patients who were poor surgical candidates;
however, radiosurgery has recently been introduced as an
effective and safe treatment option for patients with these
tumors
Understanding radiation

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GALSSCOCK JACKSON CLASSIFICATION

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GUILD HISTOLOGICAL CLASSIFICATION

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Lundgren classification

13. CLASSIFYING, STAGING THE GLOMUS JUGULARAE
Mark Trombetta/Otorhinolaryngology Clinics/2011

14. Modified Fisch classification for glomus jugulare tumors

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Salt pepper appearance
Salt and pepper appearance is seen
on both T1 and T2 weighted
sequences; the salt representing
blood products from hemorrhage or
slow flow and the pepper
representing flow voids due to high
vascularity

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Moth eaten appearance
Moth-eaten appearance is a
pattern of bone involvement by
multiple lytic lesions that is
described as permeative bone
destruction (permeative process
in bone)

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Phelps sign
EROSION OF THE
CAROTICOJUGULAR SPINE
BETWEEN THE CAROTID CANAL
AND JUGULAR FOSSA MAY BE
PRESENT (PHELP SIGN)

18. moth eaten"
appearance
RISING SUN SIGN
Radiological signs Glomus jugularae

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CASE DETAILS FOR SRS

20. History
• Patient had headache and difficulty in swallowing for past one
year
• Hoarseness of voice for past one year
• Tinnitus , reduced hearing for six months
• Nasal regurgitation for six months
• No history of vomiting/ giddiness/ blurring of vision/ diplopia/
facial weakness/ numbness or pain over face
• No history of seizure episodes/ limb weakness/ bowel and
bladder disturbances
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21. Histological Examination
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22. Presentation 2013
• Headache
• Swallowing difficulty
• Hoarseness of voice
• Tinnitus
• Hearing loss
• No facial palsy
• Nasal regurgitation
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23. imaging finding
• 2.5 x2 cm
• Left jugular foramen
• Hypo on T1
• Iso on T2
• Brilliantly enhancement
• Predominantly extrcranial
• Carotid artery pushed anteriorly
• Erosion of carotid canal and jugular foramen
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24. Sx 2013
• FISCH type approach and excision of Glomus
jugulare done on17/4/2013
• Accidental facial nerve injury and repair
• Styloid process removal
• Coagulation of tumor adherent to IJV
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25. Imaging finding
• 2.7x2.5x2.5cm mass LEFT CP ANGLE MASS
• LT JUGULAR FORAMEN
• MODERATE ENHANCEMENT
• EXTENSION INTO LT MIDDLE EAR
• ABBUTING 6TH/7TH NERVE
• 9TH/10TH NERVE NOT SEPARATED OUT
• WIDENING OF FORAMEN
• INDENTING CEREBELLAR PEDANCLE
• EXTENDING TO CAROTID CANAL AND FLOW IS GOOD
• Lesion infiltrating left jugular bulb and infiltrating proximal internal jugular
vein
• Intrcranial extension and is extradural
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26. Histology finding
• Lesion cells are arranged in well defined nests
separated by highly vasculaarised fibrous
sepatae[zelle ballen pattern]
• Synaptophysin positive
• S100 positive
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27. New presentation 2019
• Headache
• Swallowing difficulty
• Hoarseness of voice
• Tinnitus
• Hearing loss
• Facial palsy
• Nasal regurgitation
• Deviation of uvula to RT
• Deviation of tongue to RT
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28. Hearing and vision
• Bilateral vision normal
• Left severe sensory neural deafness
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29. • Right parasaggital and parafalcine T2 hyper
intense
• Flair [ central hypo and peripheral hyper]
• DWI- no restriction
• S/o- infarct
MRI FINDING
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30. BONY DESTRUCTION ON CT

31. CISTERNAL DISPLACEMENT ON MRI

32. MOTHEATEN ON MRI

33. SALT PEPPER APPEARANCE ON MRI

34. Final Diagnosis
• Glomus jugularae of left jugular bulb
• Prior embolized
• Prior surgery
• Recurrent
• With long cranial nerve palsy
• GALSSCOCK JACKSON grade lll
• Guild classification 2
• LUNDGREN classification 2
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35. • NEUROSURGEON
• INTERVENTIONAL RADIOLOGIST
• RADIATION ONCOLOGIST
MULTI DISCIPLINARY DISCUSSION
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36. Tumor board decision
• After group discussion with neurosurgeon,
radiation oncologist and interventional
radiologist, board decided to plan for
stereotactic radiotherapy
• Patient was explained about complications
and outcome of the procedure
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37. STEREOTACTIC RADIOSURGERY
PLAN of treatment
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38. Patient discussion
• Discussed about the procedure
• Discussed about imaging and follow up
• Discussed about obliteration rate
• Discussed about the complications
• Discussed about the repeat SRS
• Discussed about post radiotherapy raised ICT
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39. • How it works?
• Is emobilization needed?
• What is obliteration rate?
• How will be the follow up
• Complication and rates?
Answering patient specific questions
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40. Dose selection-PLAANED FOR-14Gy
ZACHARY D. GUSS/RADIOSURGERY OF GLOMUS JUGULARE TUMORS:
A META-ANALYSIS/ IJROBP/2011

41. Expected complications
ZACHARY D. GUSS/RADIOSURGERY OF GLOMUS JUGULARE TUMORS:
A META-ANALYSIS/ IJROBP/2011

42. • Planned for SRS
• Single fraction
• 14Gy/1# marginal dose
Radiation tumor board
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43. Simulation
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44. MRI protocol
• T1/T2/FLAIR sequence- Usual sequence
• MR ANGIO
• 3D FSPGR contrast- Normal anatomy
• 512x 512 matrix
• 1mm slice
• No gap
• No tilt
• Neutral neck
• FOV should include body contour nose,
eye and skull
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45. • 1mm slice
• Contrast
• Vertex to neck
• With SRS mask
• CT contrast and ANGIO
Planning CT
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46. Basics of target delineation
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• Delineate the enhancing part and non enhancing
visible part
• Bony erosion part

47. • GTV is delineated
• VOLUME- 10.531cc
• Multiplanar evaluation
Target delineation GTV
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48. MULTIPLANNAR CT – MR FUSION

49. GTV WITH PTV 1MM

50. OAR

51. DELINEATING 8TH NERVE

52. PTV
1. 1mm
2. VOLUME-14.710CC
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53. Smooth your contour-PTV
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54. • VOLUME- 1189.175CC
Brain-PTV
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55. • VMAT
• D-ARC
• 3DCRT
• IMRT
Planning
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56. SL NO PARAMETER VALUE
1 D MAX 17.35Gy
2 D95% 14.67Gy
3 D100% 12Gy
4 V95% 99.51%
5 V14Gy[V100%] 98.87%
6 V15.40Gy[110%] 71.06%
7 V16.80Gy [120%] 2.99%
8 V130% 0%
9
Dmean 15.7Gy
1. Prescription Isodose level is usually not 100% PD covering 100% PTV
2. Often 95% PD covering 95% PTV or higher
3. Or 100% PD covering 95% PTV or higher.
Michael Torrens,/J Neurosurg (Suppl 2)/2014
PTV coverage index
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57. • FORMULA
• VOLUME OF PRESCRIPTION ISODOSE/PTV VOLUME
• 19.742/14.71=1.34
• DESIRABLE=1
[Sonja Petkovska
Proceedings of the Second
Conference on Medical Physics and
Biomedical Engineering]
RTOG conformity index
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58. • FORMULA
(VOLUME OF PRESCRIPTION ISODOSE IN AREA OF INTEREST)2
PTV VOLUME X VOLUME OF PRESCRIPTION ISODOSE
• 15.839x 15.839/14.71 X19.742
• Here- 0.86
• IDEAL= > 0.85. AND <1
Michael Torrens,/J Neurosurg (Suppl 2)/2014
Paddick conformity index
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59. • FORMULA
• MAXIMUM DOSE/PRESCRIPTION DOSE
• 17.35Gy/14Gy=1.23
• DESIRABLE = 1.1-1.3
HOMOGENITY index
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60. • Dose fall off observation is very much needed in this
evaluation under headings
• Gradient index
• Difference between various isodose lines
• e.g between 80% and 60%- ideal- <2mm
• Between 80% and 40%- ideal- < 8mm
• For that reason we have to calculate equivalent
radius
Dose fall off
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61. • To evaluate dose gradient we have to find out
difference between radius of various isodose line
• But none is iso spherical
• We have to find out equivalent radius from formula
• First find out the specified isodose volume
• Then calculate the radius
• V=4/3 πr3
• r= (3V/4π)1/3
Equivalent radius
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62. SL NO PARAMETER VOLUME RADIUS
1 100% ISODOSE 15.839cc 1.68mm
2 80% ISODOSE 33.104CC 1.99mm
3 60% ISODOSE 52.493CC 2.32mm
4 50% ISODOSE 69.39CC 2.55mm
5 40% ISODOSE 98.47CC 2.86mm
r= (3V/4π)1/3
Equivalent radius
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63. • FORMULA
– Difference of equivalent radius of prescription
isodose and equivalent radius of 50% isodose
• 2.55mm-1.68mm=0.87mm
• It should be between 0.3 to 0.9
Gradient index
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64. • BETWEEN 80% AND 60%- IDEAL-<2mm
– HERE- 2.32-1.99=0.33mm
• BETWEEN 80% AND 40%- IDEAL- <8mm
– HERE- 1.99-2.86=0. 87mm
EORTC-22952-26001
Distance between various isodose lines
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65. • Requirement V12Gy = 10cc
• Achieved =3.597cc
BMP - BRAIN MINUS PTV
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66. FLICKINGER CURVE -12Gy VOL. BASED ON LOCATION
JOHN C. FLICKINGER/IJROBP/2000
Symptomatic post SRS injury according to
location & 12-Gy-Volume for AVM in temporal,
parietal, cerebellar, corpus callosum, medulla,
and basal ganglia locations.
Symptomatic post SRS injury according to
location & 12-Gy-Volume for AVM in frontal,
intraventricular, cerebellar, occipital, thalamic,
and pons/midbrain locations
CHANCES OF NECROSIS
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68. CONSTRAINTS
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69. SL NO ORGAN DESIRABLE ACHIEVED
1 RT. EYE MAX <8Gy <1Gy
2 LT. EYE MAX <8Gy 1.3Gy
3 RT. OPTIC NERVE MAX <8Gy <1Gy
4 LT. OPTIC NERVE MAX <8Gy 1.64Gy
5 OPTIC CHIASM MAX <8Gy <1Gy
8 BRAIN STEM MAX <15Gy 10.55Gy
9 RT. COCHLEA MAX <9Gy 1.44Gy
10 LT. COCHLEA MAX <9Gy 14.66Gy
GG HANNA/CLINICAL ONCOLOGY/2016
OAR coverage
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70. DVH

71. DVH STATISTICS

72. BEAM ARRANGEMENTS

73. ISODOSE LINES
COLOUR ISODOSE LINE
Green PTV
Red 100%
orange 80%
Yellow 60%
pink 50%
Blue 40%

74. • MECHANICAL ISOCENTER CHECK
– WINSTON LUTZ TEST
• POINT DOSE VERIFICATION
• TOLERANCE-1MM
Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015
QA part
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75. Dry run
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76. • CBCT CORRECTIONS
Set-up verification-CBCT
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77. • HEXAPOD CORRECTIONS
Set-up verification- HEXAPOD
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78. PREMEDICATION
• Tab. Dexamethasone 8mg thrice daily starting day
before
• Tab. Ondansetron 8mg thrice daily starting day
before
• Tab. Pan 40 once daily starting day before
• Antiepileptic for 6-8 weeks
• Diabetes care if
• Taper the steroid over 3 weeks
• Anti emetics
• PROTON PUMP INHIBITOR
Peri medication
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79. • Imaging after 6 months
Advised
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80. Acknowledgments
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Dr P S Bhattacharya

81. DOCTORS
• Dr P S Bhattacharya
• Dr C R Kundu
• Dr V K Reddy
• Dr Sajal Kakkar
• Dr Deepak Gupta
PHYSICISTS
• MR A C PRABU
• MR A SRINU
• MR PRASAD
• DR ANIL KUMAR
TECHNOLOGIST TEAM
Acknowledgments
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