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A 6-year-old girl developed a glioblastoma in the basal ganglia and brain stem 5 years after surgical excision and local irradiation (5460 cGy) for craniopharyngioma. Clinical and histological details are presented, and the literature on radiation-induced gliomas is reviewed.
Fourteen adults and 4 children with cystic craniopharyngiomas were treated with stereotactic beta-irradiation during a 6-year period. Of these patients, 10 were primary cases, and 8 were recurrences after previous major surgery. Radioactive phosphorus (32P) or yttrium (90Y) in colloidal forms were used as the radiation agents. Cyst volumes (10-130 ml) were assessed intraoperatively by the 99Tc radiodilution method. According to our treatment program, the radiation dose to the cyst wall was 20,000 rad and the total irradiation time 2 weeks. The follow-up period ranged from 1 to 6 years, with an average of 3.8 years. Postoperative shrinkage of the cysts and clinical improvement were observed in most patients. Pertinent clinical data and results of treatment are described.
Multimodality stereotactic techniques were used in the management of 39 patients with craniopharyngiomas in a 12-year interval. Monocystic craniopharyngiomas were treated successfully by intracavitary beta-irradiation using 32P (96% cyst control rate). Solid tumor progression or secondary cyst formation required repeat irradiation, radiosurgery or microsurgery in selected patients. In the future, wider and earlier application of stereotactic techniques may further reduce the still unacceptable morbidity currently associated with initial radical microsurgical resection of craniopharyngiomas.
New interest for pituitary neurosurgery in diabetic retinopathy is based on several data: long-term efficacy of various medical therapeutic agents is still unproved, ocular treatment by photocoagulation remains symptomatic, growth-hormone (HGH) has a permissive or supportive role in the development of diabetic retinopathy. Stereo-GIHF performs the pituitary interstitial irradiation by stereotaxic implantation of a gamma point emitter (198Au) and results in the selective blockade of HGH secretion peaks. Different from all other procedures achieving a more or less complete hypophysectomy, Stereo-GIHF introduces a new trend for the functional neurosurgical treatment of diabetic retinopathy.
OBJECTIVE: Long-term follow-up data were analyzed to assess the value of intracavitary irradiation with stereotactically applied beta-emitting radioisotopes for the treatment of craniopharyngioma cysts. METHODS: Sixty-two of 70 consecutive patients with predominantly cystic craniopharyngiomas were selected for retrospective analysis. Beta-Emitting isotopes were injected intracystically using a computed tomography-guided and computer-assisted three-dimensional stereotactic treatment planning and application system (cumulative dose to the inner surface of the cyst wall, 200 Gy). RESULTS: The tumor response rate gained with yttrium-90-labeled silicate (66 of 78 cysts) or phosphorous-32-labeled chromic phosphate (8 of 78 cysts) was 79.5%. Four cysts treated with rhenium-186-labeled sulfate did not respond. Mean survival after intracavitary irradiation was 9.0 +/- 0.9 years (median follow-up, 11.9 yr). In patients with solitary cysts, the mean survival was 12.5 +/- 1.4 years (actuarial 5- and 10-yr survival rates, 80 and 64%, respectively). Six months postoperatively, visual deficits (38 of 62 patients) had improved in 23 patients and were stable in 15 patients. The side effects that occurred 6 to 12 months after treatment with yttrium-90 were complete blindness (three patients), worsening of visual field cuts (one patient), third nerve palsy (one patient), and diabetes insipidus and/or panhypopituitarism (three patients). CONCLUSIONS: Intracavitary irradiation using yttrium-90 or phosphorous-32 is highly effective in the treatment of cystic craniopharyngiomas. If applied as initial treatment in patients with solitary cysts, it is the only required therapy over a long period.
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Although radiation necrosis of the brain is a recognized complication of irradiation of the central nervous system, the psychiatric aspects of this phenomenon are less well defined. Two cases of radiation necrosis in which psychiatric symptoms were a prominent part of the clinical picture are presented. Factors that determine the evolution and clinical presentation of radiation necrosis are reviewed. In particular, the role of the consultation psychiatrist in the diagnosis and management of such patients is discussed.
Different means of therapy are available for the treatment of craniopharyngiomas (surgery, radiation therapy, radioactive implants) but their respective impact is still a matter of controversy. Computed tomographic examinations of 26 patients before and after various forms of therapy were used to monitor the efficacy of treatment. 118 scans were retrospectively studied for characteristic features. 16 patients were treated by surgery and additional radiotherapy, 10 had surgery alone. The total size of the tumour was found to be decreased in 69% of patients treated by incomplete surgery and irradiation up to 9 years after treatment, while tumor progression occurred in three patients. Where the surgeon considered that there had been excision of the lesion, evidence of residual tumour was seen in 4/8 (50%) of cases, but no regrowth occurred in these whose postoperative scans had indicate complete resection. The increase or development of calcification after radiotherapy is compatible with a silent tumour.
A study of the recurrence rate in 41 patients operated and postoperatively treated with irradiation for a pituitary adenoma was performed 10-15 years after operation. 15 of the 41 patients are now deceased among whom 1 had a known recurrence. 25 out of the now 26 living patients were investigated with a clinical examination, perimetry, computed tomography (CT), roentgen examination of the sella turcica and an endocrine evaluation. The outstanding capability of the CT to visualize pituitary adenoma recurrences was clearly demonstrated as this technique revealed recurrences in 6 patients, only 2 of which had progressive visual field defects and none progressive changes on plain sellar films.
OBJECTS: We longitudinally analysed functional capacity and quality of life (QoL) in 102 patients with a childhood craniopharyngioma during follow-up. METHODS: The Fertigkeitenskala Münster-Heidelberg (FMH) ability scale was used for QoL assessment. Multivariate analysis evaluated FMH scores at various time points, examining hypothalamus involvement (HI), body mass index (BMI), degree of resection, tumour progression, relapse and irradiation. RESULTS AND CONCLUSION: Patients without HI (n=60) self-assessed higher QoL at baseline (p=0.001) and follow-up (p<0.001) than patients with HI (n=42). Only patients without HI evaluated at baseline >12 months after diagnosis showed longitudinal improvement in FMH scores (p=0.040). Rates of incomplete resection and irradiation were higher (p=0.070 and p=0.002 respectively) in patients with HI. In multivariate analysis, only HI, tumour relapse, progression, baseline FMH score, and time between diagnosis and baseline evaluation had independent impact on QoL. HI, tumour progression, and relapse had long-term QoL affects-most notably, severe obesity.
Intracavitary irradiation of intrasellar cystic craniopharyngeomas by stereotactic cyst puncture and injection of radioactive solutions is not yet possible. Therefore we designed a new method which allows such intracavitary irradiation. Its principle is a transphenoidal approach with only a small bony opening of the sella floor, followed by cyst puncture, exclusion of cyst leakage by Metrizamid injection under x-ray control, injection of Y-90-colloid solution at a dosage which delivers a radiation of 200 Gy to the cyst wall, and finally tight closure of the puncture site using fibrin glue and gelfoam. This method has been used in three patients with good results (follow-up 12-15 months) and without complications. Even though long-term follow-up is not yet available, our preliminary results suggest that this method will be useful for future patients with intrasellar cystic craniopharyngeomas.
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Craniopharyngioma, often with cystic diliatation, is difficult to resect radically. Fifty patients with huge craniopharyngioma (diameter of tumor was over 5 cm) treated with intratumoral irradiation of radioactive isotopes (32P and 90Y) through CT-guided Leksell stereotactic system are reported. The patients were 2 to 69 years of age with the disease of 1- to 12-year duration. Of the 50 patients, 21 had recurrent tumor after craniotomy, 29 without surgery operation before. All tumors were confirmed pathologically. The major clinical symptoms were as follows: visual field defect, headache, vomiting, diabetes insipidus, hemiplegia and growth retardation in juvenile cases. There was no death or serious complications following the treatment procedure. Partial response (> 50% reduction of tumor size on CT scanning with improvement of symptoms and signs) rate of the treatment was 82.0% at one month and 62.0% at 2 to 7 years after treatment.
In a 30-year-old male, multiple cerebral aneurysms developed 19 years after receiving 60 Gy of irradiation for craniophariginoma. Angiogram revealed right IC-PC and upper basilar trunk aneurysms in addition to atherosclerotic change. The right IC-PC aneurysm was wrapped and the basilar trunk aneurysm located between the origins of SCA and AICA was treated by endovascular coil embolization. The packing of the aneurysm was complete, but stenosis of the basilar artery appeared. The patient was discharged uneventfully and follow-up angiogram 6 months later demonstrated that the aneurysm had disappeared and the patency of the basilary artery had been preserved. Radiation-induced intracranial vasculopathy is a well-recognized phenomenon, but aneurysm formation is less common than arterial occlusive lesion. However, the mortality rate after bleeding is so high that immediate diagnosis and treatment by direct surgery or coil embolization are necessary.