Chapter 91 Radiotherapy of Nonmalignant Diseases

*Adapted from Simpson^23

Table 3: Clinical outcomes of stereotactic radiosurgery or external beam radiotherapy (with or without surgery) for meningiomas in modern series.

Study (year)	Patient No.	Radiation	S+R/R	Dose (median or mean)	Local Control (%)
Ganz et al. (2009) ^37	97	SRS	NA	12 Gy	100% (2 yrs)
Takanisha et al. (2009) ^43	101	SRS	24%/76%	13.2 Gy	97% (1 yr)
Han et al. (2008) ^38	98	SRS	36%/64%	12.7 Gy	90% (5 yrs)
Iway et al. (2008) ^40	108	SRS	NA	12 Gy	93% (5 yrs), 83% (10 yrs)
Kondziolka et al. (2008) ^42	972	SRS	49%/51%	14 Gy	87% (10 yrs)
Davidson et al. (2007) ^35	36	SRS	100%/0%	16 Gy	100% (5 yrs) 95% (10 yrs)
Feigl et al. (2007) ^36	214	SRS	43%/57%	13.6 Gy	86.3% (4 yrs)
Hasegawa et al. (2007) ^39	115	SRS	57%/43%	13 Gy	87% (5 yrs) 73% (10 yrs)
Kollova et al. (2007) ^41	368	SRS	30%/70%	12.5 Gy	98% (5 yrs)
Zachenhofe et al. (2006) ^44	36	SRS	70%/30%	17 Gy	94% (9 yrs)
Goldsmith et al. (1994) ^28	117	EBRT	100%/0%	54 Gy	89% (5 yrs) 77% (10 yrs)
Mendenhall et al. (2003) ^29	101	EBRT	35%/65%	54 Gy	95% (5 yrs) 92% (10 yrs)
Nutting et al. (1999) ^31	82	EBRT	100%/0%	55-60 Gy	92% (5 yrs) 83% (10 yrs)
Vendrely et al. (1999) ^32	156	EBRT	51%/49%	50 Gy	79% (5 yrs)

*Adapted from Minniti et al.^30 Abbreviations, S=surgery; R=radiation; SRS = stereotactic radiosurgery; EBRT = external beam radiotherapy

Table 4: Chandler staging system for Juvenile Nasopharyngeal Angiofibroma.

Stage	Description
I	Confined to nasopharynx
II	Extension into nasal cavity and/or sphenoid sinus
III	Extension into ≥ 1 of the following: cheeks, infratemporal fossa, pterygomaxillary fossa, ethmoid sinus, maxillary antrum
IV	Intracranial extension

*Adapted from Chandler et al.^96 Please see references [97] and [98] for the Fisch and Radkowski staging, respectively.
Table 5: Clinical results of radiotherapy in Juvenile Nasopharyngeal Angiofibroma

Study	No. Patients	Study Period	Dose (Gy)	Local Control	Side Effects
Chakraborty et al. (2011) ^99	9	2006-2009	30-46	87.5% (2 yrs)	No late toxicity
Mcafee et al. (2006) ^101	22	1975-2003	30-36	90% (10 yrs)	Cataracts (6), transient CNS syndrome (2), “in field” BCC (2)
Lee et al. (2002) ^100	27	1960-2000	30-55	85% (5 yrs)	15% late toxicity (growth retardation, panhypopituitarism, TLN, cataracts)
Reddy et al. (2001) ^102	15	1980-1991	30-35	85% (5 yrs)	Cataracts (3), CNS syndrome (1), BCC (1)

Abbreviations: CNS=central nervous system; BCC=basal cell carcinoma; TLN=temporal lobe necrosis


Table 6: Flickinger’s predicted rates of in-field AVM obliteration based on the minimum dose within the target volume.

Minimum Dose to Target (Gy)	Predicted AVM obliteration Rate (%)
27	99
25	98
22	95
20	90
17	80
16	70
13	50

*Adapted from Flickinger et al., Figure 2.^112

Table 7: SPECS classification system for Graves’ ophthalmopathy.

Clinical Feature	Grade 1 (1 point)	Grade 2 (2 points)	Grade 3 (3 points)
S (soft tissue involvement)	Minimal objective symptoms: redness, chemosis, slight periorbital edema	Moderate objective symptoms: redness, chemosis; moderate periorbital edema	Severe objective symptoms: conjunctival exposition, prominent periorbital edema
P (proptosis)	>20-23 mm	24-27 mm	>27 mm
E (eye muscle dysfunction)	Rare diplopia; none in parimary position	Frequent diplopia; moderate mobility impairment	Severe constant muscular dysfunction
C (corneal involvement)	Slight corneal changes and no symptoms	Prominent corneal changes and moderate symptoms	Keratitis or other severe eye symptoms
S (sight loss)	20/25 – 20/40	20/45 – 20/100	>20/100

Table 8: Clinical guidelines for use of radiotherapy in Graves’ ophthalmopathy (GO)

Radiotherapy Goal	Precondition/Indications	Contraindications
Induce clinical regression	Pretherapeutic diagnostics: evidence of autoimmune thyroid disease; CT/MRI	Stable GO without clinical progression
Reduce/eliminate functional deficits	Ophthalmologic diagnostics: documented progressive disease	Lack of euthyrosis
Improve cosmetics/esthetics	Subjective/objective findings: evidence of functional deficits and disorders	“Cosmetic” indication alone without functional impairment
Avoid/decrease undesired effects of other measures	Exclusion of risk factors: no other eye disease (i.e. diabetic retinopathy)	No consent to planned therapy

*Adapted from Donaldson et al.^166

Table 9. Radiation therapy mechanism of action dose concepts
Mechanisms of Action	Single Dose (Gy)	Total Dose (Gy)
Cellular gene and protein expression (e.g., eczemas)	<2.0	<2
Inhibition of inflammation in lymphocytes (e.g., in pseudotumororbitae)	0.3–1.0	2–6
Inhibition of fibroblast proliferation (e.g., in keloids)	1.5–3.0	8–12
Inhibition of proliferation in benign tumors (e.g., in desmoids)	1.8–3,0	45–60

FIGURE LEGENDS

Figure 1: Radiosurgery treatment plan of a patient with a right optic nerve sheath meningioma treated to a dose of 24 Gy in 3 fractions. The lesion is intensely enhancing on the post-contrast stereotactic MRI sequences. Panel 1 demonstrates the dose-volume histogram for the patient. The maximum dose to the ipsilateral optic nerve was 22.3 Gy. Panels 2-4 demonstrate the isodose curves for the treatment in the axial, sagittal and coronal planes. The 100% (24 Gy) isodose line is green, the 88% (21 Gy) isodoseline is in orange and the 50% (12 Gy) isodose line is blue.
Figure 2: A-B) A recurrent non-functioning pituitary adenoma seven years after surgical resection in the axial (A) and coronal (B) planes. The yellow arrows denote invasion into the left cavernous sinus. C-E) Rapid arc intensity-modulated radiotherapy treatment plan for the same patient in the axial (C), coronal (D) and sagittal (E) planes. The PTV (purple shaded area) was prescribed 50.4 Gy in 28 fractions.
Figure 3: Axial, coronal, and sagittal MRI images of a patient with multicystic (yellow arrows) craniopharyngioma prior to treatment.
Figure 4: A) Stereotactic radiosurgery plan for an AVM (red) in the dorsal pons treated with 22 Gy in 2 fractions. The prominent streak artifacts are present due to embolization one year prior to treatment. B) CT angiogram of the same patient used to assist in defining the AVM nidus (red contour).
Figure 5: Stereotactic MRI sequences (Panel 1) demonstrating the contoured anterior limbs of the internal capsule bilaterally and the corresponding treatment plan for the right internal capsule (Panel 2) for a patient with refractory obsessive-compulsive disorder. The right internal capsule was prescribed 70 Gy to the 50% isodose line (140 Gy maximum dose) in a single fraction.
Figure 6: A-B) 50-year old woman with Graves’ ophthalmopathy before (A) and after (B) treatment with corticosteroids and radiotherapy for prominent eyelid edema and strabismus. C) 3D-conformal radiotherapy treatment plan for a patient with Graves’ ophthalmopathy. The isocenter (yellow arrow) is placed a few mm posterior to the lenses (magenta), and the opposing fields are beam split anteriorly (white arrows). The extraocular muscles are contoured in red. The color wash display demonstrates that less than 10% of the dose reaches the lens.
Figure 7:  Dupuytren’s contracture of both hands and the left foot [Use figure from previous version of chapter].
Figure 8:  Immobilization for treatment of Dupuytren’s contracture with electrons.
Figure 9: A: Keloid behind left earlobe. B: Status of keloid following resection plus 4 × 4 Gy radiotherapy. [Use figures from previous version of chapter].
Figure 10: Typical treatment field for HO.