Meningioma accounts for about one-third of adult brain tumors (population incidence 7.61 per 100,000). The incidence increases with age and is higher in women. In most cases, this is a benign tumor (WHO - World Health Organization Grade I). Benign meningioma (as opposed to atypical (Grade II) or malignant (Grade III) meningioma) is not a significant cause of mortality but can cause severe morbidity1. Anterior visual pathway meningioma (AVPM) in most cases is benign and grows slowly over years but can impair one or more visual functions: visual acuity (VA), visual field (VF), or color vision. The injury can be unilateral or bilateral depending on the tumor's location relative to the anterior visual pathway (AVP): near the optic tract, the optic chiasm, optic nerve, or involving the optic nerve sheath. The tumor may cause diplopia due to compression of cranial nerves III, IV and VI in the cavernous sinus or in the orbit 2,3. Without treatment, deterioration of vision functions4 and finally blindness5 occur.
In most cases, AVPM is diagnosed by imaging (without pathological verification) and is not operable. The common treatment is FSRT6, accurate radiation therapy designed to stop tumor growth and prevent deterioration of visual functions. The method's stereotactic component relates to using a patient-specific immobilization system while assimilating a recent imaging test, thus producing a patient/tumor-specific 3D coordinate system used throughout the treatment7. The optimal fractionation scheme – the daily dose of radiation and the total number of doses – for safe and effective treatment of AVPM is undetermined8–12. In our institution, most AVPM cases receive conventionally fractionated stereotactic radiotherapy (cFSRT), employing 28–30 daily doses of 1.8-2 Gy per day for a total dose of up to 54 Gy.
AVP structures exhibit greater sensitivity to single-fraction irradiation than other cranial nerves in the cavernous sinus, perhaps more so in patients with a pre-existing visual deficit due to tumors or previous surgery13,14. In many AVPM cases, there is an impairment in visual functions (to varying degrees) even before treatment is given4. Radiation toxicity can damage optic pathways and impair their functions, particularly by radiation-induced optic neuropathy (RION). It is hypothesized that the mechanism of damage in RION is an ischemic disorder followed by necrosis of the optic nerve and the optic chiasm, typically occurring three months to several years after radiotherapy completion, with peak incidence after 1 to 1.5 years15. Important risk factors for RION include total radiation dose (over 50Gy), higher dose per radiation fraction, advanced age, previous exposure to chemotherapy, or optic nerve compromise at the beginning of radiation therapy.15 No effective treatment for RION has been found, driving the need for careful consideration of radiation regimen, and raising the importance of estimating radiation toxicity risk for tumors adjacent to AVP. Other factors that have been described to influence meningioma treatment outcome include residual tumor volume after surgery and pathology report of WHO grade, with atypical and malignant tumors entailing worse prognosis 16,17.
Rogers et al. reviewed the treatment of meningioma and concluded that a total dose of up to 50Gy for optic nerve sheath meningioma (ONSM) and AVPM produced good results16. Stiebel-Kalish et al. reported their results and reviewed previous publications on cFSRT (1.7-2Gy / fraction, for a total of 50-60Gy) for AVPM6. In their study, tumor control was achieved in 14 of the 16 patients, with shrinkage of size in three patients during a mean follow-up of 39mo. Two cases progressed, one in an area that was outside the radiation field. Visual function improved or stabilized in 8 of the 16 patients and worsened in 2 (12%). In published data, we found permanent deterioration in visual acuity or visual field in only 23 out of 1191 patients after cFSRT (2.1%, see Additional File 1 for references). This rate corresponds to the risk of damage to optic nerves and chiasm summarized by Mayo et al.18, based mostly on descriptive publications with relatively small samples. The differences between published studies in outcome variables, therapeutic equipment, and follow-up periods make it difficult to reach conclusions, especially since some studies did not consider tumor progression (PD) as a variable that may affect the outcome.
Radiobiological models suggesting that higher daily doses are at least as effective as lower daily doses, and possibly more effective, while shortening treatment courses, led to abbreviated radiation regimens, termed hypofractionation (hSRT)19. Compared to cFSRT, hSRT uses higher daily radiation doses with shorter treatment duration. Choosing between these regimens for meningiomas in direct contact with the AVP is a double-edged sword: high-dose fractions reaching the sensitive blood supply of the optical system could lead to vascular damage and late secondary toxicity with loss of vision; on the other hand, a suboptimal dose could cause visual function deterioration as a result of PD.
Several series of patients with AVPM treated by hSRT have been published, with the caveat of insufficient reporting of dosimetric analysis for AVP structures or detailed measurement of visual function: Conti et al.8 reviewed previous publications reporting hSRT treatment of AVPM and described "controlled tumor growth" and lack of "optic nerve toxicity" in a series of 25 patients treated with 2–5 doses of 4-10Gy each. Hiniker et al.20 summarized previous publications (including Emami et al.21 and later information from QUANTEC22) and reported results of treating peri-optic tumors by hSRT in up to five fractions; they suggested both hSRT and SRS were safe treatment options. Marchetti et al.23 reported the results of treating 143 patients with hSRT (25Gy in 5Gy sessions over five consecutive days). VA change (worsening or improvement) was defined as one or more Snellen lines. VF deterioration was defined as an increase in the defect area. The authors reported a visual worsening rate of 7.4% (5.1% after excluding cases with PD). Conti et al.12 reported a multicenter retrospective heterogeneous cohort of 341 patients with skull-base meningiomas, and compared cFSRT to hSRT. Visual toxicity was reported for one case (0.49%) of mild visual disturbance in hSRT vs. one case (0.7%) of moderate optical pathway toxicity in cFSRT. Most recently, Marchetti et al.24 published results of 167 patients treated with 5X5Gy hSRT. The authors reported an overall visual worsening rate of 5.5%, or 3.7% if excluding PD patients with no details regarding the test used.
In light of the paucity of sufficiently detailed information, the present study investigated the relationship between the radiation therapy regimen (hSRT vs. cFSRT) and the change in visual function (visual acuity and visual fields), measured at last neuro-ophthalmologic evaluation compared to pre-treatment.