Conventional Radiation Therapy in Primary Optic Nerve Sheath Meningioma
Conventional RT provided consistently good results in patients with pONSM. However, more recent, 3D conformal and stereotactic RT achievements in this disease showed that the latter two techniques have major advantage over more traditional 2D RT. This is
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Contents
K ey P oin t s 7.1
Postoperative Radiation Therapy 77
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7.2 Exclusive Conventional Radiation Therapy 80
Conventional RT provided consistently good results in patients with pONSM. However, more recent, 3D conformal and stereotactic RT achievements in this disease showed that the latter two techniques have major advantage over more traditional 2D RT. This is so regarding both tumour control and toxicity. Both issues are superiorly addressed by more sophisticated, computer-driven technologies based on superior imaging. They led to excellent visual outcome and very low toxicity that would jointly lead to completely abandoning the use of conventionally planned and executed (2D) RT from this setting.
7.1
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References 82
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Postoperative Radiation Therapy Surgery and radiation therapy can be combined both ways, as either postoperative (adjuvant) radiotherapy or post-radiotherapy (adjuvant) surgery. While the majority of the data come from the postoperative setting, some of the recent reports indicated that surgery can be practiced in cases with severe, progressive visual loss and optic disk oedema not only before, but also after radiation therapy (Turbin et al. 2006). Postoperative radiation therapy has traditionally followed surgery that had been described as either bi-
B. Jeremić, MD, PhD International Atomic Energy Agency, Wagramer Strasse 5, P.O. Box 100, 1400 Vienna, Austria
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opsy or partial/subtotal resection or complete tumour resection. It has mostly been practiced in cases when primary ONSM extended to the intracranial sites with clearly documented visual impairment. In such cases, although there is presumably bigger bulk of the primary tumour, resection of both intraorbital and intracranial component of the disease should be attempted at the same time. Resection of as much tumour as possible should be an ideal goal. It should, however, be switched to a subtotal resection if no clear resection planes are identified around the optic nerve to minimize visual loss, if possible at all. In such cases postoperative RT was frequently administered. Several studies at the end of the 1980s showed that this might be an effective approach (Ito et al. 1988; Kennerdell et al. 1988; Kupersmith et al. 1987). In a series of Kupersmith et al. (1987), there were three groups of patients treated between 1965 and 1984 at New York University Medical Center. One (group A; n = 4) had received radiation therapy as the primary
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radiation therapy initially. In one patient, with a visual acuity of NLP because of an apical tumour, the orbital apex with optic nerve was removed via a craniotomy. Twenty years later, intracranial and sinus spread were noted but the patient refused further surgery and was treated with radiation therapy. After 3 years of follow-up, radiologic and clinical findings were stable. The second patient had subtotal removal of an ONSM and maintained with a visual acuity of 20/30 for 7 years, after w
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