Gamma Knife for large and giant Lesions
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Gamma knife is considered unsuitable for lesions larger than 10cc. In this presentation, the author- Prof Deepak Agrawal- Gamma-Knife expert and an accomplished neurosurgeon shows how this size criteria is a myth
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Gamma Knife for large and giant Lesions
- 1. Gamma Knife for Giant intracranial lesions: An Indian’s perspective Dr Deepak Agrawal, Professor, Neurosurgery & Gamma Knife, All India Institute of Medical Sciences, N Delhi
- 2. Large Most authors have defined large VSs as lesions with one dimension > 3 cm, but the tumor volume has not yet been defined. >10cc is considered large in recent literature Fractionated Gamma Knife Radiosurgery as Initial Treatment for Large Skull Base Meningioma. Hye Ran Park, Jae Meen Lee, Kwang-Woo Park, Jung Hoon Kim, Sang Soon Jeong, Jin Wook Kim, Hyun-Tai Chung, Dong Gyu Kim, Sun Ha Paek. Exp Neurobiol. 2018 Jun; 27(3): 245–255.
- 3. Are ‘large’ Lesions unsuitable for GK All definitions of ‘large’ are based on Vestibular schwannomas & classical teaching of medium & large for VS Extrapolated to other lesions without any scientific merit!
- 4. Why 3cm & 4cm limits No actual guidelines in place. No literature on volume limits for gamma knife In 1983, Kjellberg et al. constructed a 1% dose volume isoeffect line that was used as a guideline for radiotherapy dose prescriptions at his center. Kjellberg RN, Hanamura T, Davis KR, Lyons SL, Adams RI: Bragg-Peak proton-beam therapy for arteriovenous malformations of the brain. N Engl J Med 1983;309:269–274
- 7. Brain Metastasis Initially less than 3 metastasis were only considered suitable It is now clear treating even 20 or more brain mets with GK is better than WBRT! No 1 indication of GK in USA!!! Kim CH, Im YS, Nam DH, Park K, Kim JH, Lee JI. Gamma knife radiosurgery for ten or more brain metastases. J Korean Neurosurg Soc. 2008;44(6):358-63. Hatiboglu MA, Tuzgen S, Akdur K, Chang EL. Treatment of high numbers of brain metastases with Gamma Knife radiosurgery: a review. Acta Neurochir (Wien). 2016 Apr;158(4):625-634.
- 8. CASE STUDIES- AIIMS, N DELHI We defined Giant lesions as > 20cc
- 9. Skull Base meningioma (4 years FU) Volume: 53.09cc At GK FU Imaging after 4 Years
- 10. Glomus (5 Years FU) Volume: 64.93 cc At GK FU Imaging after 5 Years
- 11. Giant Acoustic (6 years FU) Vol: 66.19cc At GK FU Imaging after 6 Years
- 12. Glomus (3 Years FU) Vol: 65.79 cc At GK FU Imaging after 3 Years
- 13. High Grade Glioma (1 year FU) Vol: 83.72 cc At GK FU Imaging after 1 Year
- 14. AIIMS Data >20 cc(giant Lesions) Jan 2012- Dec 2017 (6 years) Minimum 1 year FU
- 15. AIIMS Data (>20cc) 37 Meningioma 32 AVM 17 Glomus 3 Acoustic 3 Pituitary 34 Others
- 16. AIIMS Data FU available in 55% 27% static 62% decreased 11 % increased
- 17. ADVANTAGES OVER EBRT Can be repeated if required Decreased incidence Radiation changes/ edema Cognitive decline
- 18. Limitations to dosing in GK Extremely long treatment times Proximity to critical structures’: Optic pathway Brainstem
- 19. oxymoron /ˌɒksɪˈmɔːrɒn/ Noun a figure of speech in which apparently contradictory terms appear in conjunction ‘Unsuitable for Gamma-Knife’
- 20. CONCLUSIONS GAMM KNIFE MAY BE SUITABLE IN SELECTED LARGE/GIANT LESIONS WITH BETTER OUTCOMES AND DECREASED TOXICITY AS COMPARED TO CONVENTIONAL RADIOTHERAPY