A highly vascular intracranial solitary fibrous tumor treated with radiotherapy and toremifene: case report.

OBJECTIVE AND IMPORTANCE: A case of an unusual intracranial solitary fibrous tumor with features of high vascularity and resultant difficulty at resection is presented. The use of surgery, radiotherapy, and toremifene has been successful with no recurrence after 18 months. CLINICAL PRESENTATION: A 33-year-old male patient presented with a 1-year history of loss of vision on the left side and a 3-month history of headache and lethargy. Magnetic resonance imaging showed a lobulated mass (7.6 x 4.5 cm) in the left temporal fossa and left parasellar, sellar, and suprasellar regions, with a "dural tail" more typical of meningioma. Vascular supply was from both the internal carotid arteries and the left middle meningeal artery, precluding embolization. INTERVENTION: At the time of the craniotomy, a highly vascular tumor was found. Intraoperative hemorrhage limited resection to 20% of the tumor. The histological diagnosis was of a solitary fibrous tumor with an unusually angiomatoid architecture. After the operation, radiotherapy and toremifene were administered. A dramatic reduction in the size of the tumor was seen with no recurrence to date. CONCLUSION: The use of surgery, radiotherapy, and toremifene in treatment of a vascular intracranial solitary fibrous tumor has been successful and warrants further research.

Comparison of a micro-multileaf collimator with a 5-mm-leaf-width collimator for intracranial stereotactic radiotherapy.

PURPOSE: To dosimetrically compare a micro-multileaf collimator (minimum leaf width of 3 mm) with the 5-mm-leaf multileaf collimator (MLC) of a standard linear accelerator for stereotactic conformal radiotherapy treatment of intracranial lesions. MATERIALS AND METHODS: Fourteen patients previously treated for a variety of irregularly shaped intracranial lesions using BrainLAB's micro-MLC were retrospectively replanned using the Varian Millennium MLC (5 mm leaf width). All planning was performed with the BrainSCAN v 5.1 software. The same fixed, noncoplanar beam arrangement was used for both plans, and identical target coverage was achieved by adjusting the MLC shape around the planning target volume (PTV). The isodose distributions and dose-volume histograms (DVH) were computed and plans were compared in terms of conformity of the prescription isodose to the PTV and dose received by surrounding normal tissue. RESULTS: Equivalent PTV coverage was achieved using the 5-mm collimator by adjusting the MLC shape around the target in every case. There was a statistically significant increase in the conformity index for the Varian MLC compared with the micro-MLC (p < 0.001), indicating a worse conformity of the prescription isodose to the PTV, but this parameter was within our (and Radiation Therapy Oncology Group) clinical criterion in all cases. There was no statistically significant difference in the maximum dose to critical structures, but DVH curves demonstrated an increased volume of normal tissue irradiated to the lower isodose levels. The mean increase in the volume of critical structure enclosed within the 50% and 70% isodose surfaces was 5.7% and 4.9%, respectively. CONCLUSIONS: The micro-MLC consistently improves both PTV conformity and surrounding tissue sparing when compared to that of a standard linear accelerator. However, when viewed quantitatively, the improvements are small enough that individual centers may question their choice of equipment when outfitting a stereotactic radiotherapy service.

Stereotactic radiosurgery XVI: Isodosimetric comparison of photon stereotactic radiosurgery techniques (gamma knife vs. micromultileaf collimator linear accelerator) for acoustic neuroma--and potential clinical importance.

PURPOSE: Two stereotactic photon radiation therapy methods are currently in practice for the treatment of acoustic neuroma. In the 1990s, our data and those of others demonstrated isodosimetric advantages for gamma knife technology over linear accelerator methodology. Since then, the introduction of micromultileaf collimator technology has improved the conformity of the linear accelerator method such that the isodosimetric differences between the two techniques have narrowed. MATERIALS AND METHODS: In this study, modern gamma knife isodosimetry was compared to that of modern linac technology (conformal fixed fields and dynamic arcs) for the therapy of acoustic neuroma. This is an unusual target in that a special sensory nerve (holding the key to hearing preservation) frequently runs through the targeted volume, unlike the majority of other stereotactic radiation therapy targets. This was a single-dose prescription comparison; the perceived extra benefit of fractionation (a technique not routinely available to the gamma knife) was thereby abrogated. RESULTS: Although the gamma knife technique maintained a slight, but statistically significant, advantage with regard to dose conformity (p < 0.02) (at the debatable cost of a lower minimum target dose), the much higher internal dose gradient (high maximum dose to prescription dose [MD:PD] ratio) could be interpreted as a disadvantage with respect to hearing preservation, although advantageous with regard to tumor ablation. Of the two linac methods, the dynamic arc method gave a statistically significant advantage over the fixed-field method as regards conformity (p < 0.05), at the expense of a slightly higher brainstem dose (an average of 12.4 Gy, cf. 11.7 Gy for fixed fields), but this result was not statistically significant. No significant difference was seen in the MD:PD ratio for the two single-isocenter linac techniques. CONCLUSIONS: Gamma knife methodology remains well validated, with very good isodosimetry, but when hearing preservation is important, the improving linac technologies will compete with the gamma knife for optimal therapy. In these circumstances, the minor differences in isodosimetry between the two techniques will become important.