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ABSTRACT: The authors report a case of Dropped Head Syndrome with an unusually rapid onset after an accident in a patient with a history of Hodgkin's lymphoma cured by chemotherapy and mantle field radiotherapy and compare this case to the rare published cases of chronic Dropped Head Syndrome occurring after this type of treatment. A 56-year-old man was treated at the age 36 years for supra-diaphragmatic Hodgkin's lymphoma by chemotherapy and mantle field radiotherapy according to a standard technique and standard doses (40Gy, 20 fractions, 27 days). Seventeen years after the end of treatment, he experienced a violent whiplash injury, rapidly followed by a Dropped Head Syndrome, similar to the cases of chronic Dropped Head Syndrome already described in the context of Hodgkin's lymphoma (permanent flexion of the head, only reduced in the supine position). Physical and neurophysiological examination, electromyogram, and magnetic resonance imaging confirmed the diagnosis of Dropped Head Syndrome. Very few treatment options are available for the major disability related to Dropped Head Syndrome. This type of subacute onset of Dropped Head Syndrome has not been previously described. The good results of radiation therapy after chemotherapy allow a dose reduction to 30Gy in the involved regions. This, together with recent progress in treatment planning, should allow eradication of these complications.
Cancer/Radiothérapie 12/2012; · 1.49 Impact Factor
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V Nataf,
K Kerrou,
S Balogova,
F Pene,
V Huchet,
F Gutman,
A Prignon,
I-P Muresan,
C Giannesini,
V Izrael, M Schlienger,
J-N Talbot
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ABSTRACT: PET with fluoroethylthyrosine (FET), amino-acid analogue, has been performed in Germany since the beginning of the decade for molecular and metabolic imaging of brain tumours, since FDG, the glucose analogue which is the reference tracer for clinical PET, has this drawback to be taken-up intensely by cerebral cortex. We report on our preliminary results on the comparison of PET/CT with FET and FDG in 10 evaluable patients presenting with a brain lesion either at diagnosis or after treatment. In an attempt to optimise specificity, FET PET/CT has been acquired as a static image 1h after injection, while the most current practice is a dynamic 40 min acquisition starting at FET injection. With our acquisition protocol, diagnostic performance of FET was 88% sensitivity and 80% accuracy vs 13% and 30% respectively for FDG. CONCLUSION: FET is a radiopharmaceutical with clinical usefulness for the diagnosis, delineation and monitoring of brain tumours. Association with FDG allows identification of high-grade lesions or components, but it could be avoided providing that acquisition and quantification procedures of FET PET/CT would have been better optimised and standardised.
Bulletin du cancer 04/2010; 97(5):495-506. · 0.67 Impact Factor
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ABSTRACT: A survey of the literature has been performed to find arguments in order to help the choice between radiosurgery and hypofractionated stereotactic radiotherapy in the treatment of brain metastases.
A comparison of two groups of brain metastases treated with hypofractionated stereotactic radiotherapy or radiosurgery, with or without WBRT was performed. Hypofractionated stereotactic radiotherapy: there were eight series including 448 patients published from 2000 to 2009; treated with 5-6 MV X-Rays, non invasive head immobilization, a margin 2 to 10mm; 24 to 40Gy in three to five fractions; a 5 to 8 days duration in six series and 15-16 days in two other series. WBRT (30%) ; radiosurgery: there were 12 series (1994 to 2005) including 2157 patients; an invasive head immobilization, no margin; doses from 10 to 25 Gy; six series over 12 had Gamma Knife radiosurgery and six had Linacs X-Rays. WBRT (30 Gy/10 F/12 days) associated to radiosurgery in several series. The following parameters were compared: median GTV, median survival, 1-year survival rate, local control rate, necrosis and WBRT rates.
Hypofractionated stereotactic radiotherapy series: the parameters were respectively: 0,52-4,47 cm(3) (median 2,8 cm(3)); 5-16 months (median 8,7 months); 68,2-93% (median 82,5%); necrosis rate 3,1%; associated WBRT 30%. Radiosurgery series: the parameters were respectively: 1,3 to 5,5 cm(3) (median 2 cm(3)); 5,5 to 22 months (median 11 months); 71 to 95% (median 85%); 0,5 to 6% (median 2,4%); associated WBRT 58%. Results seem similar in the two groups: Hypofractionated stereotactic radiotherapy with non invasive immobilization could theoretically treat all brain metastases sizes except lesions<10 mm (500 mm(3)). In large volumes,>4200 mm(3) GTV, the toxicity of hypofractionated stereotactic radiotherapy was not reported, thus it was difficult to compare its results with the published reports of radiosurgery toxicity. WBRT was a confusing parameter. Obviously, this initial survey has important limitations, specifically its methodology.
Radiosurgery and hypofractionated stereotactic radiotherapy could be used to treat brain metastases with GTV>500 mm(3) and < or = 4200 mm(3) (Ø 20mm); for GTV<500 mm(3) (Ø 10mm) an invasive procedure with radiosurgery is necessary. For GTV>4200 mm(3) (Ø 20mm), hypofractionated stereotactic radiotherapy could be proposed, provided further studies, using 4 to 6 Gy fractions, a duration less or equal to 10-12 days and a margin of 2mm will be performed.
Cancer/Radiothérapie 12/2009; 14(2):119-27. · 1.49 Impact Factor
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ABSTRACT: To evaluate our results after radiation therapy and concomitant chemotherapy in terms of local control, survival and toxicity in patients with anal cancer.
Between November 1990 and January 2002, 60 patients (pts) were treated with radiation therapy and concomitant chemotherapy. The T-stage according to the 2001 UICC classification were: 2 T1, 26 T2, 25 T3, and 7 T4. There were 20 pts with nodal involvement at presentation. The treatment started with external beam RT (median dose: 45 Gy) and concomitant chemotherapy using 5-fluorouracil and cisplatin during the first week and the fifth week of external beam RT (EBRT). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 58 pts and by interstitial (192)Ir brachytherapy in 2 pts. Mean follow-up were 78.5 months.
At the end of RT with concomitant chemotherapy local tumor clinical complete response rate was 83%. Out of 10 non responders or local progression, 5 (50%) were salvaged with abdominoperineal resection (APR). Out of 5 local tumor relapses, 3 were salvaged with APR. The overall local tumor control (LC) rate with or without salvage local treatment were 88%. LC rate with a good anal function scoring (score 0 and 1) was 70%. Among 43 pts who preserved their anus, 98% had a good anal function scoring. The 5-year disease-free survival was 75%. After multivariate analysis, 2 independent predicting factors significantly influenced the disease-free survival: HIV-positive pts (negative vs positive, P=0.032) and clinical tumor response after the first course of radiotherapy (<50% vs >or=50%, P=0.00032). Acute grade 2 or 3 toxicities were low: haematological toxicity in 4 pts and intestinal complication corresponding to diarrhea in 10 pts. Late severe complication was observed in 3 pts: 2 pts with painful necrosis of the anus requiring colostomy and 1 pt with grade 3 rectal bleeding.
We confirm the good results with RT and concomitant chemotherapy. The clinical tumor response after the first course of RT and concomitant chemotherapy is probably the most important predictive factor on the disease-free survival. For patients with T3 or T4 lesion and tumor regression <or=50% after the first course of radiation therapy, surgical non conservative treatment should be discussed.
Cancer/Radiothérapie 12/2006; 10(8):572-82. · 1.49 Impact Factor
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ABSTRACT: Inverse problems are encountered in physical problems over a large field of applications. In medicine many applications treat the inverse problem. For example the problems of X-rays or gamma-rays Computed Tomography, radiography, positron imaging are of this kind. The inverse problem was encountered in classical radiotherapy, in a partial form, searching the best possible radiation dose distribution for a given treatment situation. The last years the stereotaxic radiosurgery technique was used for the treatment of small brain malformations. The great precision of this technique and the high level of the dose delivered during unique irradiation, necessitate the use of one optimisation treatment method. We propose an optimisation method which has the following caracteristics. In opposition to the classical radiotherapy methods, the dose distribution formation procedure is considered in its globality, taking into account all the pixels of the dose matrix. We realize a deep analysis of the radiosurgery problem, examining the conditionning of the problem. This analysis is based on the singular values decomposition. The goal of the method is to find physically acceptable solutions of the weights vector for a given irradiation configuration, for obtain a predifined dose distribution.
04/2006: pages 1129-1140;
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ABSTRACT: Dose distribution optimization algorithms are necessary in pencil-beam radiotherapy to exploit efficiently the multiple parameters of this powerful irradiation technique. We propose as an optimization technique singular value decomposition (SVD) analysis, which allows the measurement of ill conditioning of the stereotactic radiotherapy inverse problem and yields optimal weights for conformal treatment. Our approach to dose distribution optimization is to recover estimates of the minibeams weights from well-defined previsional dose matrices to study the influence of the different parameters on the stereotactic radiotherapy inverse procedure. The adjustment of the different parameters of the stereotactic irradiation to the “SVD optimizer” procedure is realized taking into account the ratio of the quality reconstruction to the calculation time. It will permit a more efficient use of the SVD optimizer in clinical applications with real three-dimensional lesions. We show the efficiency of the SVD optimizer in analyzing and predicting ill conditioning in stereotactic radiotherapy and in recognizing the topography of the different beams to create an optimal vector containing the beam weights (reconstructed weighting vector).
International Journal of Imaging Systems and Technology 10/2005; 6(1):104 - 113. · 0.78 Impact Factor
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F Nataf,
M Koziak,
A-C Ricci,
P Varlet,
B Devaux,
F Beuvon,
T Roujeau,
P Page,
C Cioloca,
B Turak, [......],
E Touboul,
C Haie-Meder,
J-M Vannetzel,
F Dhermain,
J Honnorat,
A Jouvet,
G De Saint-Pierre,
C Daumas-Duport,
P Bret,
F-X Roux
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ABSTRACT: Incidence of cerebral oligodendrogliomas is increasing because of better recognition made possible by improved classifications. We studied a homogeneous series using the Sainte-Anne grading scale in order to better understanding the history of these tumors with or without treatment and to assess prognosis and associated factors.
A retrospective series of 318 adult patients with oligodendroglioma (OLG) treated at Hôpital Sainte-Anne, Paris (SA) and Hôpital Neurologique, Lyons (L) between 1984 and 2003 was analyzed: 182 grade A OLG (SA + L), 136 grade B among which a homogenous series of 98 (SA) were included. For grade A: age at diagnosis ranged from 21 to 70 (mean: 41), sex ratio was 1.28. For grade B: age at diagnosis ranged from 12 to 75 (mean: 45.5), sex-ratio was 1.58. The main first symptoms were: epilepsy (A: 91.5%; B: 76%), intracranial hypertension (A: 7.9%; B: 14.6%), neurological deficit (A: 5.1%; B: 17.7%). The most frequent locations were: frontal, insular and central for both A and B. Mean size was 55 mm for grade A, 62 mm for B. Calcifications were found in 20% of A, 48.5% of B. No tumor was enhanced on imaging (CT/MRI) in grade A, all but 7 in grade B. All patients underwent surgery either for biopsy (A: 47.2%; B: 53%), or removal which was partial (A: 26.4% vs B: 19.4%) or extended (A: 36.3% vs B: 37.8%). Fifty-six patients underwent 2 procedures and 12 three procedures. Radiotherapy was performed in 76.9% of grade A, and 91% of B patients, in the immediate postoperative period for 71% A and 82.7% B. Chemotherapy was delivered for 36% of grade A (in the event of transformation to grade B or failure of radiotherapy) and 67.5% of B patients. Among grade A tumors, 38% transformed into grade B within a mean delay of 51 months with a mean follow-up of 78 months.
Median survival was 136 months for grade A and 52 for grade B. Survival at 5, 10 and 15 was 75.5%, 51% and 22.4% for grade A vs 45.2%, 31.3% and 0% for grade B respectively. In univariate and multivariate analysis, grade A survival was associated with age at diagnosis, tumor size, large removal and response to radiotherapy. Grade B survival was associated with age at diagnosis, wide removal and sharply defined limits of the tumor on imaging.
Analysis of both published data and this series underlines many prognostic parameters. It shows that OLG are heterogeneous tumors even in each grade (A and B). Treatment should consequently progress towards more targeted procedures for patients mainly with postoperative radiotherapy and chemotherapy.
Neurochirurgie 10/2005; 51(3-4 Pt 2):329-51. · 0.34 Impact Factor
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E Touboul,
L Moureau-Zabotto,
D Lerouge,
F Pène,
E Deniaud-Alexandre,
E Tiret,
A Sezeur,
S Houry,
D Gallot,
R Parc, M Schlienger,
A Laugier
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ABSTRACT: Since 1980, curative-intent radiation therapy of epidermoid carcinoma of the anal canal is the standard first line treatment. The combined concomitant chemotherapy and radiation therapy is presently established for locally advanced tumors more than 4 cm in length and/or with nodal involvement. We report the Tenon hospital experience since 1972 concerning the long term results after radiation therapy, the modifications of the radiation technique, and the evolution of treatment strategy.
Cancer/Radiothérapie 12/2003; 7 Suppl 1:91s-99s. · 1.49 Impact Factor
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E Deniaud-Alexandre,
E Touboul,
E Tiret,
A Sezeur,
S Houry,
D Gallot,
R Parc,
R Huang,
S H Qu,
F Pène, M Schlienger
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ABSTRACT: To identify prognostic factors and treatment toxicity in a serie of epidermoid cancers of the anal canal without evident metastasis.
Between June 1972 and January 1997, 305 patients (pts) were treated with curative-intent radiation therapy (RT). The T-stages according to the 1987 UICC classification were: 26 T1, 141 T2, 104 T3, and 34 T4. There were 49 pts with nodal involvement at presentation. Pretreatment anal function scoring according to our in-house system was: 22 scored 0, 182 scored 1, 74 scored 2, 7 scored 3, 11 scored 4, and 9 not available pts. The treatment started with external beam RT (EBRT) in 303 pts (median dose: 45 Gy). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 279 pts and by interstitial 192Ir brachytherapy (Bcy) in 17 pts. Seven pts received only one course of EBRT (mean dose: 49.5 Gy) and 2 pts were treated with interstitial 192Ir Bcy alone (55 and 60 Gy, respectively). Concomitant chemotherapy (5-fluoro-uracil and either mitomycin C or cisplatin) was delivered to 19 pts. Mean follow-up was 103 months.
At the end of RT local tumor clinical complete response (cCR) rate was 80%. Out of 61 non responders or local progressive tumors 27 (44%) were salvaged with abdominoperineal resection (APR). The rate of local tumor relapse (LR) was 12%. Out of 37 LTR, 20 (54%) were salvaged with APR and one with interstitial 192Ir Bcy. The orevall local tumor control (LC) rate with or without salvage local treatment was 84%. LC rate with a good anal function scoring (score 0 and 1) was 56.5%. Among 181/186 available pts who preserved their anus, 94% had a good anal function scoring. For a subgroup of 15 pts with length tumor <2 cm-N0, the LC rate after the end of RT was 100%, the LC rate with or without local salvage treatment was 100%, and among 13 available pts who preserved their anus, the anal function scoring was good in 12 pts (92%). The 10-years disease-free survival was 74%. After multivariate analysis, 3 independent predicting factors significantly influenced the disease-free survival: gap duration between 2 courses of RT (>38 days vs < or =38 days, P =0.0025), pretreatment anal function scoring (0 vs 1 vs 2 vs 3 vs 4, P =4.4 10(-6)), and cCR after the end of RT (no complete response vs complete response, P =2.5 10(-14)).
We confirm excellent results with RT in T1 and T2 lesions. However, chemoradiotherapy should be prefered to improve survival free of colostomy with a good anal sphincter function for tumors more than or equal to 2 cm in length and locally advanced tumors.
Cancer/Radiothérapie 08/2003; 7(4):237-53. · 1.49 Impact Factor
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G Noël,
J L Habrand,
H Mammar,
D Pontvert,
C Haie-Méder,
D Hasboun,
P Moisson,
R Ferrand,
A Beaudré,
G Boisserie,
G Gaboriaud,
A Mazal,
K Kérody, M Schlienger,
J J Mazeron
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ABSTRACT: Prospective analysis of local tumor control, survival, and treatment complications in 44 consecutive patients treated with fractionated photon and proton radiation for a chordoma or chondrosarcoma of the skull base.
Between December 1995 and December 1998, 45 patients with a median age of 55 years (14-85) were treated using a 201-MeV proton beam at the Centre de Protonthérapie d'Orsay, 34 for a chordoma and 11 for a chondrosarcoma. Irradiation combined high-energy photons and protons. Photons represented two-thirds of the total dose and protons one-third. The median total dose delivered within the gross tumor volume was 67 cobalt Gray equivalent (CGE) (range: 60-70).
With a mean follow-up of 30.5 months (range: 2-56), the 3-year local control rates for chordomas and chondrosarcomas were 83.1% and 90%, respectively, and 3-year overall survival rates were 91% and 90%, respectively. Eight patients (18%) failed locally (7 within the clinical tumor volume and 1 unknown). Four patients died of tumor and 2 others of intercurrent disease. In univariate analysis, young age at time of radiotherapy influenced local control positively (p < 0.03), but not in multivariate analysis. Only 2 patients presented Grade 3 or 4 complications.
In skull-base chordomas and chondrosarcomas, the combination of photons with a proton boost of one-third the total dose offers an excellent chance of cure at the price of an acceptable toxicity. These results should be confirmed with a longer follow-up.
International Journal of Radiation OncologyBiologyPhysics 10/2001; 51(2):392-8. · 4.11 Impact Factor
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E Touboul,
Y Belkacémi,
L Buffat,
E Deniaud-Alexandre,
J P Lefranc,
P Lhuillier,
S Uzan,
D Jannet,
M Uzan,
M Antoine,
C Ginesty,
V Ganansia,
M Jamali,
J Milliez,
J Blondon, M Schlienger
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ABSTRACT: To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas.
Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system, underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of RT was not randomized and depended on the usual practices of the surgical teams. Group I: 79 pts received preoperative uterovaginal brachytherapy (mean total dose [MD]: 57 Gy). Group II: 358 pts received postoperative RT (196 pts received vaginal brachytherapy alone [MD: 50 Gy], 158 pts had external beam pelvis RT [EPRT] [MD: 46 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 17 Gy], and 4 pts had EPRT alone [MD: 46 Gy over 5 weeks]). The mean follow-up was 128 months.
The 10-year disease-free survival rate was 86%. From 57 recurrences, 12 were isolated locoregionally. Multivariate analysis showed that independent factors decreasing the probability of disease-free survival were: histologic type (clear cell carcinoma, p = 0.038), largest histologic tumor diameter > 3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.0055), and 1988 FIGO staging system (p = 9.10(-8)). In group II, the addition of EPRT did not seem to improve locoregional control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were FIGO stage (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. EPRT independently increased the 10-year rate for grade 3 and 4 late radiation complications (R.R.: 5.6, p = 0.0096).
EPRT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in a subgroup of intermediate risk patients (stage IA grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with stage III tumor are not satisfactory.
Cancer/Radiothérapie 09/2001; 5(4):425-44. · 1.49 Impact Factor
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ABSTRACT: BACKGROUND AND PURPOSE: The purpose was to present the successive steps of dosimetric planning and the different means used to allow the choice of the best solution among several planning projects considering the anatomical and clinical features of arteriovenous malformation. Method. Four successive steps were: A study of these factors for 5 different plannings of a clinical case using different isocenters is presented and the results are discussed. CONCLUSION: For complex arteriovenous malformations several hours are often necessary to permit physicians/radiotherapists to elaborate planning which is often a compromise among several solutions.
Neurochirurgie 06/2001; 47(2-3 Pt 2):228-38. · 0.34 Impact Factor
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ABSTRACT: To study dosimetric implications of our group dose prescription methodology on a series of 408 cerebral arteriovenous malformations.
and method. Between January 1990 and July 1998, 408 patients with cerebral arteriovenous malformations that had never been irradiated before, were treated radiosurgically in a single fraction at Tenon Hospital. 223 patients were treated with a single isocentre and 185 with multiple isocenters. Dosimetric characteristics have been studied as a function of the global quality index of planning, defined our group as the standard deviation of the differential dose volume histogram calculated in the lesion.
One percent correlation obtained between some dosimetric data and the global quality index of planning allowed to modelize by linear equations the connection between this quality index and minimum isodose in the lesion, mean doses and isodoses in the underdosed part of the lesion and in the complete lesion. This was done for mono isocentric cases and multi isocentric cases.
Before the choice of the therapeutic dose and prescription isodose, it is therefore possible from the global quality index of planning to foresee isodoses modelized by the defined equations. So, the radiotherapist can compensate using the prescription since conformity is not perfect and thus attenuate healthy tissues overdosage.
Neurochirurgie 06/2001; 47(2-3 Pt 2):239-45. · 0.34 Impact Factor
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ABSTRACT: BACKGROUND AND PURPOSE: Description of the irradiation technique used by our group since 1986 for radiosurgery of cerebral arteriovenous malformations using Xrays minibeams from a linear accelerator. Method. The technique was elaborated by O. Betti in the early 80. He used several coronal arcs to irradiate the center of the target with X rays circular minibeams. Their diameter (6 to 20 mm) is chosen according to the size of the nidus. The patient is seated in a specially built armchair. His head is immobilized with the Talairach frame afixed in the calvarium by 4 special screws: they allow to remove the frame after stereotactic angiography and/or CTscan and to replace it to perform the stereotactic irradiation. The frame and the head rotate around an horizontal axis passing by the linac isocenter ie the center of the target volume. The combination of both movements: rotation of the Linac and rotation of the stereotactic frame covers a spherical sector representing the surface of portals of entry of the minibeams. The frame can slide on a plate allowing access to the entire brain. Results. The special seat and the frame are movable on curved rails allowing to avoid or reduce irradiation of the body of the patient. CONCLUSION: We have been using this system of irradiation in the seated position since 1986 to treat more than 900 patients.
Neurochirurgie 06/2001; 47(2-3 Pt 2):246-52. · 0.34 Impact Factor
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ABSTRACT: We present a review of current technological progress enabling improvement in the quality of stereotactic irradiations: imaging fusion; individual adaptation of dosimetric planning to the shape of the target thanks to several collimation systems, spatial modulation of the beam with the use of multileaf microcollimators, beam intensity modulation, robotisation of the materials, owing to hardware and software developments.
Neurochirurgie 06/2001; 47(2-3 Pt 2):260-6. · 0.34 Impact Factor
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F Nataf,
L Merienne, M Schlienger,
D Lefkopoulos,
J F Meder,
E Touboul,
J J Merland,
B Devaux,
B Turak,
P Page,
F X Roux
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ABSTRACT: After a review of the main radiosurgical published series, to evaluate our own series of 705 patients with cerebral arteriovenous malformations treated by radiosurgery alone or in combination with embolization or surgery.
and method. From January 1984 to December 1998, 705 patients were treated by a multidisciplinary team including neurosurgeons, neuroradiologists, radiophysicians and radiotherapists. Age of revelation of the cerebral arteriovenous malformations ranged between birth to 73 years (mean 27, median 25). Age at time of radiosurgery ranged between 7 and 75 years (mean 33, median 31). There were 410 males for 295 females (sex- ratio 1.4). Symptoms of revelation were hemorrhage for 59%, seizures for 23%, headaches for 14% and progressive deficits for 4%. Discovery of cerebral arteriovenous malformation was fortuitous in 4% of cases. Repartition following Spetzler's grading was 12% in grade I, 36% in grade II, 40% in grade III, 12% in grade IV and 0% in grade V. Maximal size ranged between 4 and 60 mm (mean 23, median 20). Volume ranged between 0.2 and 24.3 cc (mean 3.8, median 2.8). Majority of cerebral arteriovenous malformations were large size (42% with size higher than 25 mm) and large volume (54% higher than 10 cc. 54% of patients had treatment prior radiosurgery: 38% had embolization, 10% were operated, 4% were treated by radiosurgery (reirradiation) and 3% were operated and embolized.
Overall complete obliteration rate was 55%. The obliteration rate was correlated with size (77% for cAVMs lower than 15 mm, 62% for cerebral arteriovenous malformations between 15 and 25 mm, and 44% for cerebral arteriovenous malformations higher than 25 mm), with volume (94% for cerebral arteriovenous malformations lower than 1 cc, 64% between 1 and 4 cc, 48% between 4 and 10 cc, and 62% for cerebral arteriovenous malformations higher than 10 cc), dose at reference isodose, minimal dose, morphological parameters (presence of dural components, arteriolovenous fistula, plexiform angioarchitecture, arterial steal, arterial recruitment, deep exclusive drainage, venous plicature, venous confluence, venous ectasia, venous reflux), sectional topography and good recovery of the target. Embolization was a confusion factor not associated with obliteration rate. After multivariate analysis, only Dmin and complete coverage of the cerebral arteriovenous malformations were correlated with obliteration rate. Delay of obliteration was significantly correlated after multivariate analysis with Dmin, complete coverage, arteriolovenulary angioarchitecture (positive correlation) and venous ectasia (negative correlation).
Overall complete obliteration rate is unreliable data to assess efficacy of radiosurgical method in the tretment of cerebral arteriovenous malformations. The obliteration rate must be interpretated after stratification on several morphological and dosimetric parameters.
Neurochirurgie 06/2001; 47(2-3 Pt 2):268-82. · 0.34 Impact Factor
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ABSTRACT: The aim of this paper is to analyze retrospectively the reasons for the failure in cerebral arteriovenous malformations radiosurgery. Several factors are evoked and discussed mainly: inaccurate target, intentional partial irradiation, repermeabilization of a previously embolized cerebral arteriovenous malformation. The results suggest the necessity of a complete irradiation of the nidus. The strategy of partial volume irradiation should be avoided, even if it necessitates lowering of the doses in large cerebral arteriovenous malformations. Accuracy in the target determination is required and a complete stereoangiography is necessary.
Neurochirurgie 06/2001; 47(2-3 Pt 2):311-7. · 0.34 Impact Factor
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ABSTRACT: Radioinduced lesions after radiosurgery of cerebral arteriovenous malformations may be associated with an increased signal on T2-weighted and gadolinium enhancement on T1-weighted MR images. They do not have necessarily a poor prognosis. These lesions are mostly asymptomatic. But in a few cases they can be associated with severe clinical symptoms which can become corticodependant or corticoresistant. We present the 5 cases of such cerebral arteriovenous malformations treated by radiosurgery, out of our series of 705 patients. The removal was easier than that of untreated cerebral arteriovenous malformations, and led to a complete recovery of symptoms and progressive decrease of imaging abnormalities. Such surgery should be proposed in case of symptomatic radioinduced lesions which fail to respond to steroids.
Neurochirurgie 06/2001; 47(2-3 Pt 2):318-23. · 0.34 Impact Factor
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ABSTRACT: Between 20 to 50% of cerebral arteriovenous malformations treated with radiosurgery (RS) fail to obliterate 2 to 5 years after irradiation. Patients are not protected against the risks leading to treatment. Two therapeutic options can be used to eradicate the persisting nidus: micro-surgery and a second irradiation. Our group has reirradiated 39 such patients.
From 1989 to 2000, 39 patients have been reirradiated (14 females and 25 males; median age 31 years). There were more left lesions: 59% than right (35%) and 5% on midline. The most frequent locations were: temporal 12 cases; parietal 8 cases; frontal 7 cases; thalamus 7 cases. The predominant first symptoms were hemorrhage (68.5%) and seizure (15.8%). Prior RS, 21/39 patients had embolization (53.8%) and 3 surgery. Method. Treatment has been performed with the same system for the first and the second radiosurgery for 37 patients. Planification and dosimetry improved during that period. The level of dose was similar for the 2 RS. MRI has been used as a non invasive follow-up tool.
Only 28 patients were evaluable because 7/39 patients had the second radiosurgery in 1999 or in 2000 and data were lacking at the time of writing for 4 patients. Obliteration rate was 17/28 (60.7%). Nine patients bled between the two radiosurgery procedures. Complications: 4 new regressive deficits occurred after the second radiosurgery. The rate of parenchymal changes were higher, after the second radiosurgery. Except one patient who died of a non-related affection 2 years after obliteration of his cerebral arteriovenous malformation, thus 38/39 patients were alive.
This series was small compared to the potential number of candidates suffering from failure of the first radiosurgery, but the results are promising.
Neurochirurgie 06/2001; 47(2-3 Pt 2):324-31. · 0.34 Impact Factor
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ABSTRACT: Risks of bleeding from partially or unobliterated cerebral arteriovenous malformations remain unchanged. A complementary treatment should be indicated after radiosurgery. In this brief review the following data are discussed: the reasons of second treatment, imaging follow-up of cerebral arteriovenous malformations after radiosurgery, types of cerebral arteriovenous malformations to be treated, timing and therapeutic modalities.
Neurochirurgie 06/2001; 47(2-3 Pt 2):332-5. · 0.34 Impact Factor
