Benefits of image-guided stereotactic hypofractionated radiation therapy as adjuvant treatment of craniopharyngiomas. A review
Craniopharyngiomas account for 5.6–13% of intracranial tumors in children. Despite being histologically benign, these tumors remain a major neurosurgical challenge because of the typical tight adherence to adjacent critical structures. The optimal therapeutic approach for this disease is controversial. Large cystic size and adherence to neurovascular, neuroendocrine, and optic structures without a clear line of cleavage make complete resection problematic and often hazardous. For these reasons, partial resection and adjuvant treatment play an important role. Post-operative radiation therapy (RT) following either complete or incomplete tumor removal is associated with significantly decreased recurrence rates. The aim of this review is to analyze the potential advantage of the most modern technical advancements for RT of craniopharyngiomas.
This narrative review on the topic of craniopharyngiomas was based on published data available on PUBMED/Medline. All data concerning adjuvant or upfront radiation therapy treatment of craniopharyngioma were reviewed and summarized. A more detailed analysis of fractionated frameless steretactic radiosurgery of these tumors is provided as well.
We reviewed the possible improvement provided by intensity modulated beams, arc therapy, image guidance, proton radiation, and fractionated stereotactic radiosurgery. Many published findings on outcome and toxicity after RT involve the use of relatively outdated RT techniques. Technologic improvements in imaging, radiation planning, and delivery have improved the distribution of radiation doses to desired target volumes and reduced the dose to nearby critical normal tissues. Currently available techniques, providing image guidance and improved radiation doses distribution profile, have shown to maintain the efficacy of conventional techniques while significantly reducing the toxicity.
Image-guided radiosurgery holds the dose distributions and precision of frame-based techniques with the remarkable advantage of multiple-session treatments that are better tolerated by sensitive peritumoral structures, such as the optic pathway and hypothalamus. This, together with the comfort of a frameless technique, candidates frameless image-guided radiosurgery to be the first option for the adjuvant post-operative treatment of craniopharyngiomas in children and young adults when total resection cannot be achieved, in particular those with hypothalamic involvement, and when the residual tumor is mostly solid.
KeywordsRadiation therapy Image-guided Stereotactic radiosurgery Craniopharyngioma CyberKnife
Compliance with ethical standards
Conflict of interest
Authors declare that there is no conflict of interest and no competing interest.
- 1.Muller H (2018) Craniopharyngioma - a chronic disease. Swiss Med Wkly 148:w14548Google Scholar
- 4.Bulow B, Attewell R, Hagmar L, Malmstrom P, Nordstrom CH, Erfurth EM (1998) Postoperative prognosis in craniopharyngioma with respect to cardiovascular mortality, survival, and tumor recurrence. J Clin Endocrinol Metab 83:3897–3904Google Scholar
- 7.Muller HL, Gebhardt U, Schroder S, Pohl F, Kortmann RD, Faldum A, Zwiener I, Warmuth-Metz M, Pietsch T, Calaminus G, Kolb R, Wiegand C, Sorensen N (2010) Analyses of treatment variables for patients with childhood craniopharyngioma--results of the multicenter prospective trial KRANIOPHARYNGEOM 2000 after three years of follow-up. Horm Res Paediatr 73:175–180CrossRefGoogle Scholar
- 9.Habrand JL, Saran F, Alapetite C, Noel G, El Boustany R, Grill J (2006) Radiation therapy in the management of craniopharyngioma: current concepts and future developments. J Pediatr Endocrinol Metab 19(Suppl 1):389–394Google Scholar
- 18.Kalapurakal JA, Goldman S, Hsieh YC, Tomita T, Marymont MH (2000) Clinical outcome in children with recurrent craniopharyngioma after primary surgery. Cancer J 6:388–393Google Scholar
- 19.Merchant TE (2006) Craniopharyngioma radiotherapy: endocrine and cognitive effects. J Pediatr Endocrinol Metab 19(Suppl 1):439–446Google Scholar
- 27.Puget S, Garnett M, Wray A, Grill J, Habrand JL, Bodaert N, Zerah M, Bezerra M, Renier D, Pierre-Kahn A, Sainte-Rose C (2007) Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement. J Neurosurg 106:3–12Google Scholar
- 28.Sands SA, Milner JS, Goldberg J, Mukhi V, Moliterno JA, Maxfield C, Wisoff JH (2005) Quality of life and behavioral follow-up study of pediatric survivors of craniopharyngioma. J Neurosurg 103:302–311Google Scholar
- 33.Luu QT, Loredo LN, Archambeau JO, Yonemoto LT, Slater JM, Slater JD (2006) Fractionated proton radiation treatment for pediatric craniopharyngioma: preliminary report. Cancer J 12:155–159Google Scholar
- 34.Merchant TE, Kiehna EN, Kun LE, Mulhern RK, Li C, Xiong X, Boop FA, Sanford RA (2006) Phase II trial of conformal radiation therapy for pediatric patients with craniopharyngioma and correlation of surgical factors and radiation dosimetry with change in cognitive function. J Neurosurg 104:94–102Google Scholar
- 35.Fitzek MM, Linggood RM, Adams J, Munzenrider JE (2006) Combined proton and photon irradiation for craniopharyngioma: long-term results of the early cohort of patients treated at Harvard Cyclotron Laboratory and Massachusetts General Hospital. Int J Radiat Oncol Biol Phys 64:1348–1354CrossRefGoogle Scholar
- 36.Bishop AJ, Greenfield B, Mahajan A, Paulino AC, Okcu MF, Allen PK, Chintagumpala M, Kahalley LS, McAleer MF, McGovern SL, Whitehead WE, Grosshans DR (2014) Proton beam therapy versus conformal photon radiation therapy for childhood craniopharyngioma: multi-institutional analysis of outcomes, cyst dynamics, and toxicity. Int J Radiat Oncol Biol Phys 90:354–361CrossRefGoogle Scholar
- 39.Yomo S, Hayashi M, Chernov M, Tamura N, Izawa M, Okada Y, Hori T, Iseki H (2009) Stereotactic radiosurgery of residual or recurrent craniopharyngioma: new treatment concept using Leksell gamma knife model C with automatic positioning system. Stereotact Funct Neurosurg 87:360–367CrossRefGoogle Scholar
- 41.Chung WY, Pan DH, Shiau CY, Guo WY, Wang LW (2000) Gamma knife radiosurgery for craniopharyngiomas. J Neurosurg 93(Suppl 3):47–56Google Scholar
- 45.Saleem MA, Hashim AS, Rashid A, Ali M (2013) Role of gamma knife radiosurgery in multimodality management of craniopharyngioma. Acta Neurochir Suppl 116:55–60Google Scholar
- 47.Alafaci C, Grasso G, Conti A, Caffo M, Salpietro FM, Tomasello F (2014) Cyberknife radiosurgery for cranial plasma cell tumor. Turk Neurosurg 24:272–275Google Scholar
- 49.Conti A, Pontoriero A, Midili F, Iati G, Siragusa C, Tomasello C, La Torre D, Cardali SM, Pergolizzi S, De Renzis C (2015) CyberKnife multisession stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for perioptic meningiomas: intermediate-term results and radiobiological considerations. Springerplus 4:37CrossRefGoogle Scholar
- 50.Conti A, Pontoriero A, Ricciardi GK, Granata F, Vinci S, Angileri FF, Pergolizzi S, Alafaci C, Rizzo V, Quartarone A, Germano A, Foroni RI, De Renzis C, Tomasello F (2013) Integration of functional neuroimaging in CyberKnife radiosurgery: feasibility and dosimetric results. Neurosurg Focus 34:E5CrossRefGoogle Scholar
- 52.Conti A, Pontoriero A, Siddi F, Iati G, Cardali S, Angileri FF, Granata F, Pergolizzi S, Germano A, Tomasello F (2016) Post-treatment edema after meningioma radiosurgery is a predictable complication. Cureus 8:e605Google Scholar
- 53.Pontoriero A, Conti A, Iati G, Mondello S, Aiello D, Rifatto C, Risoleti E, Mazzei M, Tomasello F, Pergolizzi S, De Renzis C (2016) Prognostic factors in patients treated with stereotactic image-guided robotic radiosurgery for brain metastases: a single-center retrospective analysis of 223 patients. Neurosurg Rev 39:495–504CrossRefGoogle Scholar
- 54.Romanelli P, Conti A, Bianchi L, Bergantin A, Martinotti A, Beltramo G (2017) Image-guided robotic radiosurgery for trigeminal neuralgia. NeurosurgeryGoogle Scholar
- 58.Puataweepong P, Dhanachai M, Hansasuta A, Dangprasert S, Swangsilpa T, Sitathanee C, Jiarpinitnun C, Vitoonpanich P, Yongvithisatid P (2016) The clinical outcome of hypofractionated stereotactic radiotherapy with CyberKnife robotic radiosurgery for perioptic pituitary adenoma. Technol Cancer Res Treat 15:NP10–NP15CrossRefGoogle Scholar
- 60.Romanelli P, Wowra B, Muacevic A (2007) Multisession CyberKnife radiosurgery for optic nerve sheath meningiomas. Neurosurg Focus 23:E11Google Scholar
- 61.Colombo F, Casentini L, Cavedon C, Scalchi P, Cora S, Francescon P (2009) Cyberknife radiosurgery for benign meningiomas: short-term results in 199 patients. Neurosurgery 64: A7–13Google Scholar
- 62.Marchetti M, Bianchi S, Milanesi I, Bergantin A, Bianchi L, Broggi G, Fariselli L (2011) Multisession radiosurgery for optic nerve sheath meningiomas--an effective option: preliminary results of a single-center experience. Neurosurgery 69:1116–1122 discussion 1122–1113Google Scholar