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Gamma Knife for large and giant Lesions

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Gamma knife is considered unsuitable for lesions larger than 10cc. In this presentation, the author- Prof Deepak Agrawal- Gamma-Knife expert and an accomplished neurosurgeon shows how this size criteria is a myth

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Gamma Knife for large and giant Lesions

  1. 1. Gamma Knife for Giant intracranial lesions: An Indian’s perspective Dr Deepak Agrawal, Professor, Neurosurgery & Gamma Knife, All India Institute of Medical Sciences, N Delhi
  2. 2. Large  Most authors have defined large VSs as lesions with one dimension > 3 cm, but the tumor volume has not yet been defined.  >10cc is considered large in recent literature Fractionated Gamma Knife Radiosurgery as Initial Treatment for Large Skull Base Meningioma. Hye Ran Park, Jae Meen Lee, Kwang-Woo Park, Jung Hoon Kim, Sang Soon Jeong, Jin Wook Kim, Hyun-Tai Chung, Dong Gyu Kim, Sun Ha Paek. Exp Neurobiol. 2018 Jun; 27(3): 245–255.
  3. 3. Are ‘large’ Lesions unsuitable for GK  All definitions of ‘large’ are based on Vestibular schwannomas & classical teaching of medium & large for VS  Extrapolated to other lesions without any scientific merit!
  4. 4. Why 3cm & 4cm limits  No actual guidelines in place.  No literature on volume limits for gamma knife  In 1983, Kjellberg et al. constructed a 1% dose volume isoeffect line that was used as a guideline for radiotherapy dose prescriptions at his center. Kjellberg RN, Hanamura T, Davis KR, Lyons SL, Adams RI: Bragg-Peak proton-beam therapy for arteriovenous malformations of the brain. N Engl J Med 1983;309:269–274
  5. 5. Brain Metastasis  Initially less than 3 metastasis were only considered suitable  It is now clear treating even 20 or more brain mets with GK is better than WBRT!  No 1 indication of GK in USA!!! Kim CH, Im YS, Nam DH, Park K, Kim JH, Lee JI. Gamma knife radiosurgery for ten or more brain metastases. J Korean Neurosurg Soc. 2008;44(6):358-63. Hatiboglu MA, Tuzgen S, Akdur K, Chang EL. Treatment of high numbers of brain metastases with Gamma Knife radiosurgery: a review. Acta Neurochir (Wien). 2016 Apr;158(4):625-634.
  6. 6. CASE STUDIES- AIIMS, N DELHI We defined Giant lesions as > 20cc
  7. 7. Skull Base meningioma (4 years FU) Volume: 53.09cc At GK FU Imaging after 4 Years
  8. 8. Glomus (5 Years FU) Volume: 64.93 cc At GK FU Imaging after 5 Years
  9. 9. Giant Acoustic (6 years FU) Vol: 66.19cc At GK FU Imaging after 6 Years
  10. 10. Glomus (3 Years FU) Vol: 65.79 cc At GK FU Imaging after 3 Years
  11. 11. High Grade Glioma (1 year FU) Vol: 83.72 cc At GK FU Imaging after 1 Year
  12. 12. AIIMS Data  >20 cc(giant Lesions)  Jan 2012- Dec 2017 (6 years)  Minimum 1 year FU
  13. 13. AIIMS Data (>20cc)  37 Meningioma  32 AVM  17 Glomus  3 Acoustic  3 Pituitary  34 Others
  14. 14. AIIMS Data  FU available in 55%  27% static  62% decreased  11 % increased
  15. 15. ADVANTAGES OVER EBRT Can be repeated if required Decreased incidence  Radiation changes/ edema  Cognitive decline
  16. 16. Limitations to dosing in GK Extremely long treatment times Proximity to critical structures’: Optic pathway Brainstem
  17. 17. oxymoron /ˌɒksɪˈmɔːrɒn/  Noun  a figure of speech in which apparently contradictory terms appear in conjunction ‘Unsuitable for Gamma-Knife’
  18. 18. CONCLUSIONS  GAMM KNIFE MAY BE SUITABLE IN SELECTED LARGE/GIANT LESIONS WITH BETTER OUTCOMES AND DECREASED TOXICITY AS COMPARED TO CONVENTIONAL RADIOTHERAPY
  19. 19. THANK YOU  drdeepak@aiims.edu

Gamma knife is considered unsuitable for lesions larger than 10cc. In this presentation, the author- Prof Deepak Agrawal- Gamma-Knife expert and an accomplished neurosurgeon shows how this size criteria is a myth

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