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Proton beam stereotactic radiosurgery for pediatric cerebral arteriovenous malformations
Brian P Walcott1, Jona A Hattangadi-Gluth, Christopher J Stapleton
1Departments of *Neurosurgery and ‡Radiation Oncology, §Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; ¶Department of Radiation Oncology, University of California San Diego, San Diego, California; ‖Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Insights
Proton stereotactic radiosurgery (SRS) is a safe and effective treatment for high-risk pediatric arteriovenous malformations (AVMs). This study shows significant obliteration rates, with potential benefits for the developing brain.
Area of Science:
- Pediatric neurosurgery
- Radiation oncology
- Cerebrovascular disease
Background:
- Stereotactic radiosurgery (SRS) is the primary treatment for high-risk cerebral arteriovenous malformations (AVMs) unsuitable for surgery or embolization.
- Proton SRS offers potential advantages due to selective energy deposition, particularly for pediatric patients with developing brains.
Purpose of the Study:
- To evaluate the outcomes of pediatric patients with AVMs treated using proton SRS.
- To assess the safety and efficacy of proton SRS in this population.
Main Methods:
- Retrospective review of 44 pediatric patients (<18 years) treated with proton SRS between 1998 and 2010.
- Analysis of AVM characteristics (volume, diameter) and radiation parameters (dose, fraction).
- Median follow-up of 52 months.
Main Results:
- AVM obliteration occurred in 40.9% of patients, with partial response in 59.1%.
- Median time to obliteration was 49 months; 9% experienced post-treatment hemorrhage.
- Factors associated with obliteration included modified AVM scale, single fraction treatment, and higher radiation doses.
Conclusions:
- Proton SRS is a safe and effective treatment option for high-risk pediatric AVMs.
- The selective energy deposition of protons may reduce damage to healthy brain tissue in pediatric patients.
Background:
For cerebral arteriovenous malformations (AVMs) determined to be high risk for surgery or endovascular embolization, stereotactic radiosurgery (SRS) is considered the mainstay of treatment.
Objective:
To determine the outcomes of pediatric patients with AVMs treated with proton SRS.
Methods:
We reviewed the records of 44 consecutively treated pediatric patients (younger than 18 years of age) who underwent proton SRS at our institution from 1998 to 2010. The median target volume was 4.5 ± 5.9 mL (range, 0.3-29.0 mL) and the median maximal diameter was 3.6 ± 1.5 cm (range, 1-6 cm). Radiation was administered with a median prescription dose of 15.50 ± 1.87 CGE to the 90% isodose.
Results:
At a median follow-up of 52 ± 25 months, 2 patients (4.5%) had no response, 24 patients (59.1%) had a partial response, and 18 patients (40.9%) experienced obliteration of their AVM. The median time to obliteration was 49 ± 26 months, including 17 patients who underwent repeat proton radiosurgery. Four patients (9%) experienced hemorrhage after treatment at a median time of 45 ± 15 months. Univariate analysis identified modified AVM scale score (P = .045), single fraction treatment (0.04), larger prescription dose (0.01), larger maximum dose (<0.001), and larger minimum dose (0.01) to be associated with AVM obliteration.
Conclusion:
High-risk AVMs can be safely treated with proton radiosurgery in the pediatric population. Because protons deposit energy more selectively than photons, there is the potential benefit of protons to lower the probability of damage to healthy tissue in the developing brain.
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