Fractionated Radiation Therapy for Large and Giant Cavernous Sinus Hemangioma: A Retrospective Study

Abstract

Surgical resection has been traditionally used as a treatment for cavernous sinus hemangioma (CSH). However, this is usually difficult due to tumor vascularity and results in complications especially in large and giant CSH (volume >20 cm 3). Previous studies have reported that radiotherapy (RT) provides an alternative treatment modality for hemangiomas. However, the optimized dose and fractions which control CSH and also protect the cognitive function remain unclear. This study reports our experience in the management of symptomatic large and giant CSH. Methods: Fifty-four patients with symptomatic large (20 cm 3 <tumor volume≤40 cm 3 , 3-4 cm in diameter) and giant (tumor volume>40 cm 3 , >4 cm in diameter) CSH were enrolled in a retrospective study between January 2007 and December 2018. The prescription dose to the target margin was 50 Gy in 25 fractions. Results: The mean pre-RT tumor volume was 60.9 cm 3 which ranged from 20.2 to 230.5 cm 3. The clinical data obtained was analyzed retrospectively following a mean follow-up period of 35.0 months which ranged from 1 to 140 months. All patients experienced tumor shrinkage within 3 months after radiotherapy. There was an average mean tumor reduction of 79.7% (range, 48.4-98.5%) with no patients experiencing tumor progression and recurrence. All the 54 patients experienced symptomatic improvement within 1 month to 12 months after radiotherapy. Within the entire follow up period, no patients experienced any form of permanent complications or symptomatic radiation toxicity. Neurocognitive impairment studies were conducted before and after radiotherapy on 28 patients while the studies were conducted after the last follow up in 40 patients. The cognitive function of all the participants had normal MoCA-scores of 28.25 pre-radiotherapy. The post-treatment MoCA-scores were also clinically stable (28.04, p = 0.78), and the average MoCA-score did not show any decline until the last follow-up (27.61, p = 0.13). Conclusion: The optimal dose and fractions of radiotherapy treatment for symptomatic large and giant cavernous sinus hemangioma remain unclear. This study, therefore, used a marginal dose of 50 Gy in 25 fractions in radiotherapy and this was proven to be effective and relatively safe in the treatment of symptomatic large and giant CSHs.

Long-term outcomes of staged Gamma Knife radiosurgery for giant cavernous sinus hemangiomas: a single-center retrospective study

“…CyberKnife treatment [18][19][20] and radiotherapy 22,23 have both been reported to result in impressive tumor control and low side-effect incidence in treating large or giant CSHs, findings which also indicate the sensitivity of CSHs to radiation treatment. In comparison, the radiation dose of GKRS is distributed in layers, like an onion, which makes the radiation dose to the tumor center 2 times higher than the dose to the tumor margin.…”

“…In addition to GKRS, the reported therapies for giant CSHs include microsurgical resection, [2][3][4][5]28 CyberKnife therapy, [18][19][20] and radiotherapy. 22,23 Li et al 2 retrospectively reviewed surgical results of 47 patients with large-volume CSHs and gross-total resection in 26 (55.3%) cases with average intraoperative blood loss of 650 ml (range 100-3500 ml), and found that increased tumor size was a risk factor for unfavorable outcomes. In this study, CSH patients previously treated with GKRS were not included, and adjunct radiotherapy was recommended for patients with incomplete resection of CSHs, and excellent results were achieved.…”

“…[18][19][20] Some research findings have suggested that radiotherapy is effective in treating large (volume > 20 ml) and giant (volume > 40 ml) CSHs. 22,23 There have been few reports on GKRS treatment of giant CSHs.…”

Endoscopic endonasal transsphenoidal surgery for unusual sellar lesions: eight cases and review of the literature

“…(3) Cavernous Sinus Hemangiomas (CSHs) are rare benign vascular tumors, accounting for less than 2% of all cavernous sinus lesions ( 24 , 25 ). In our case series, Case 3 demonstrated a sellar mass infiltrating the right cavernous sinus, partially encompassing the adjacent intracavernous internal carotid artery.…”

Clinical and Radiological Response Following Single-Session Gamma Knife Radiosurgery in Cavernous Sinus Hemangiomas

“…3,15 A recent report of the use of fractionated RT in large (20-40 cc) and giant (>40 cc) CSH, with a marginal dose of 50 Gy in 25 fractions, demonstrated a mean tumor reduction of 79.7% and symptomatic improvement in all patients within 12 months. 29 Yang et al demonstrated that a personalised approach to GKRS in CSH, reserving staged procedures for large tumors resulted in 91.5% tumor volume reduction with complications in 3.7% of patients across a spectrum of 19 large and 23 giant CSH. 22 CyberKnife radiosurgery delivered as 21 Gy in 3 fractions or 22 Gy in 4 fractions also appears to be effective in giant CSH, producing 88% mean tumor reduction with no radiation-induced complications.…”