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Indian Journal of Medical Research and Pharmaceutical Sciences December 2017;4(12) ISSN: ISSN: 2349-5340 DOI: 10.5281/zenodo.1133539 Impact Factor: 3.052

© Indian Journal of Medical Research and Pharmaceutical Sciences http://www.ijmprs.com/

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EARLY VOLUMETRIC VARIATIONS IN INTRACRANIAL

MENINGIOMA AFTER LINEAR ACCELERATOR-BASED

RADIATION THERAPY Myung-Hoon Han1, Min Kyun Na1, Choong Hyun Kim1, Jae Min Kim1, Jin Hwan Cheong1,

Seong Hoon Kim2, Yong Ko3 & Young Soo Kim*3 1Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri,

Gyonggi-do 471-701, Korea 2Department of Radiation oncology, Hanyang University Medical Center, 222-1, Wangsimni-ro,

Seongdong-gu, Seoul 133-792, Korea *3Department of Neurosurgery, Hanyang University Medical Center, 222-1, Wangsimni-ro,

Seongdong-gu, Seoul133-792, Korea

Abstract

Keywords:

meningioma, volumetric

analysis, biologically

effective dose, peritumoral

edema.

Objective: This study aimed to evaluate the risk factors for early

meningioma volume expansion after linear accelerator (LINAC)-based

radiation treatment.

Methods: All reference and tumor volumes were measured using a semi-

automated 3D slicer. We estimated the volume percent change based on

the baseline volume at every follow-up point. The area under the receiver

operating characteristic curve was used to determine optimal cut-off values

of the initial tumor volumes and biologically effective dose for predicting

tumor-volume increase.

Results: A total of 32 meningiomas were detected in 28 patients who

underwent LINAC-based radiation treatment for the first time from July 7,

2014, in our hospital. We observed an increase in tumor volume during the

short-term follow-up in groups with higher initial tumor volume, higher

biologically effective dose, and older age (log rank test; p = 0.018, p =

0.021, and p = 0.004, respectively). In addition, tumor-volume increase

was significantly associated with peritumoral edema development.

Conclusions: We believe there may be a correlation between early tumor-

volume increase and peritumoral edema development post-radiation.

Therefore, precautions should be taken when treating patients with early

tumor volume increase that exceeds 15%, especially in old age, with high

initial tumor volume, and high prescription dosages.

Introduction Meningiomas are the most-common extra-axial primary intracranial nonglial neoplasm and account

for 30% of all primary intracranial tumors.[1,2] Although complete microsurgical resection is the

treatment of choice for symptomatic meningiomas, gross total resection of meningiomas is not always

possible due to several reasons such as tumor size, location, adjacent neurovascular structures, or

patient health status. Radiation therapy has been used as an alternative treatment for meningiomas

when the remnant tumor is present after surgery or when surgical resection is not an option.[3]

However, tumor-volume expansion and peritumoral edema (PTE) are frequent complications

occurring after radiation therapy for intracranial meningiomas. Most previous studies reported the

occurrence of volumetric response of meningioma or PTE after gamma-knife radiosurgery.[2,4–7]

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In the current study, we aimed to evaluate the possible predictive risk factors for early volume

expansion of meningiomas by using a validated semi-automated volume-measuring tool after linear

accelerator (LINAC)-based radiation treatment. In addition, we investigated the potential association

between early volume increase in meningioma and PTE development after radiation treatment.

Materials and methods

Study patients

This study included patients who were diagnosed with meningioma and received stereotactic

radiosurgery (SRS) or normofractionated stereotactic radiotherapy (FSRT) for the first time. We

extracted data of patients from our hospital’s NOVALIS registry, which was designed for prospective

research in July 7, 2014. Demographic patient information, prescribed radiation dose, and

fractionation data were extracted from the NOVALIS registry.

All meningiomas were diagnosed by radiologic findings alone or histological confirmation following

prior resection. All radiologic findings were confirmed by 2 experienced radiologists. We only

included patients with meningioma who underwent at least one follow-up imaging (mostly magnetic

resonance imaging [MRI]) suitable for volumetric analysis. All follow-up imaging modalities used for

the study patients are presented in online Supplementary Table 1. Either SRS or FSRT was performed

within 1 week from the day when reference imagining was performed.

The study was approved by the Institutional Review Board of Hanyang University Medical Center.

Owing to the retrospective nature of the study, the need for informed consent was waived. All patient

records were de-identified and anonymized prior to analysis.

Radiation technique All patients were treated using the NOVALIS Tx system (Varian Medical Systems, CA, USA;

Brainlab, Feldkirchen, Germany). The noninvasive thermoplastic mask was used to perform

simulation-computed tomography (CT) for radiation treatment. The Novalis ExacTrac image system

and robotic couch included in the NOVALIS Tx system allowed us to adjust the patients’ position

according to the information from the real-time image acquisition.

Gross tumor volume (GTV) was defined as the contrast-enhanced area on T1-weighted MRI images.

For operated patients, the clinical target volume (CTV) was measured by adjusting the GTV

according to the intraoperative findings. In our hospital, all brain and spinal lesions are to be treated

by neurosurgeons. The planning target volume was defined as a symmetrical 0 to 2-mm expansion

from the GTV or CTV. In case the tumor was located near the organ at risk, we adjusted the planning

target volume with no expansion in the area of the tumor that was close to the organ at risk. A 3D

treatment-planning system, including iPlan (Brainlab, Feldkirchen, Germany) and Eclipse (Varian,

CA, USA), were used for radiation planning based on MRI/CT-fusion images in all patients (see

online Supplementary Figure 1). We tried to achieve tight conformality of the treatment isodose to the

3D reconstructed meningioma geometry. We defined FSRT as 1.6–2.2 Gy per fraction,

hypofractionated stereotactic radiotherapy (hFSRT) as 2.2–5 Gy per fraction, and SRS as single high

doses delivered in ≦5 sessions.[4] The biologically effective dose (BED) for the tumor was calculated

according to the following equation:

BED = nd × (1 + d/10), where n is the fraction, d is the dose of one fraction, and α/β = 10.


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Tumor imaging and volumetric assessment Ingenia and Achieva TX (Philips, Eindhoven, the Netherlands) 3.0 Tesla MRI scanners were used for

image acquisition in all patients. Reference and follow-up MRIs included gadolinium-enhanced axial

T1-weighted images, with a slice thickness of 1.0–3.0 mm. A CT scanner (Siemens Flash 128,

München, the Germany) was used for obtaining several follow-up images, with gadolinium-enhanced

axial images (slice thicknesses, 1.5–5.0 mm).

The 3D Slicer software is an open-source medical image-computing platform (http://www.slicer.org);

this software was used to assess the volumetric change in meningioma after radiation. All procedures

were performed by a trained 3D-Slicer user. We used the GrowCut algorithm to segment the tumor.

The detailed rationale and methods underlying the use of GrowCut for tumor segmentation using a 3D

Slicer are available elsewhere.[5] The results were manually refined upon completion of the automatic

GrowCut segmentation, especially in the prior-resection group. We defined and classified remnant

meningioma from mixed signal intensity in enhanced axial T1-weighted images with reference to

low-signal intensity on T2-weighted images in the prior-resection group. Subsequently, 3D

reconstruction was performed using the Model Maker function. The Label Statistics function was

used to calculate the volume of the 3D reconstructed tumor model (Fig. 1). The accuracy and

validation of the 3D slicer for measurement of subtle volume change in meningioma has been

reported previously.[6] We estimated the volume percent change based on the baseline volume at every

follow-up point using the following equation:

Tumor volume percent change (%) = (Volume at specific time point − Baseline volume

Baseline volume) × 100%

We performed volumetric comparisons between the reference MRIs and simulation CTs that were

used for initial MRI/CT-fusion images for radiation planning, to identify the volumetric error among a

few cases that used CTs as follow-up images. We randomly selected 3 cases among the meningioma

cases where CT was performed as the follow-up modality. The tumor volume in the simulation CT

was assessed while blinded to the tumor volume noted in the reference MRI. We present the results in

the online Supplementary Figure 2-4. We found differences of 0.18, 0.54, and 0.01 cc between the

reference MRI and simulation CT in cases 19, 25, and 31, respectively.

Definition of tumor-volume increase and PTE

PTE was defined as the radiological confirmation of newly developed PTE or progression of

preexisting PTE after radiation with newly developed neurological deficits. We defined tumor-volume

increase as a volume > 15% above the baseline volume in at least one of the follow-up images.[7]

Statistical Analysis

Meningiomas were classified into two categories: tumor-volume increase and no volume increase.

The area under the receiver operating characteristic (ROC) curve was used to determine optimal cut-

off values of the initial tumor volumes and BED for predicting tumor-volume increase during follow-

up. We used a locally weighted scatter plot smoothing curve and box-plot to graphically represent the

variation in volume percent change among meningiomas using at least 2 follow-up images on the

basis of initial tumor volume, prescribed BED for tumor, and age group. For continuous variables,

students’ t-tests were used to assess differences in the volume percent change among predictive

variables. Kaplan–Meier analysis was performed to evaluate the predictive factors for tumor-volume

increase during follow-up and the association between PTE and tumor-volume increase. Uni- and

multivariate Cox proportional hazards regression analyses were used to calculate hazard ratios (HR)

with 95% confidence intervals (CIs) for tumor-volume increase during short-term follow-up on the

basis of the predictive variables. All statistical analyses were performed using R version 3.3.2.


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Results

Patient characteristics

We included 32 meningiomas in 28 patients (women, 21 [75%]), and the average age at radiation

treatment was 59.9 years. The median initial tumor volume was 6.1 cc (interquartile range, 1.9–10.5

cc). Tumor volume increased (>15% compared to the initial volume) in 11 meningiomas (34.4%) and

5 PTEs (15.6%). Two patients underwent decompressive craniectomy and tumor removal for severe

PTE despite steroid therapy (cases 19 and 24) (see online Supplementary Figure 5). The median BED

for tumor (α/β = 10) was 45.9 Gy (interquartile range, 41.9–50.4 Gy); in addition, 4 FSRTs, and 3

hFSRTs, and 25 SRSs were performed. Median follow-up was 235.0 days (interquartile range, 154.5–

513.0 days) (see online Supplementary Table 1). Further details of patient characteristics are

presented in Table 1.

Predictors of early tumor-volume increase

We performed ROC curve analysis to evaluate predictors for early increase in tumor volume during

follow-up. We found that the area under the curve of the initial tumor volume and BED for tumor-

volume increase were 0.732 with the cutoff value of 7.876 cc and 0.712 with the cutoff value of 45.9

Gy, respectively (see online Supplementary Figure 6a and b).

Figure 2 shows the tumor-volume percent change of each meningioma using at least 2 follow-up

images based on the cutoff values of initial tumor volume and BED (7.876 cc and 45.9 Gy,

respectively) and age (65 years). There was a significant tendency of an early increase in tumor

volume in the group with high initial tumor volume compared to that with the low volume (p = 0.046)

(Fig. 2a, b). Furthermore, there was a tendency of tumor-volume increase during short-term follow-up

in the higher BED group (p = 0.027) and older age group (p = 0.001) (Fig. 2c, d). All initial and

follow-up tumor-volume information is presented in the online Supplementary Table 2.

We observed an increase in tumor volume during short-term follow-up in patients with high initial

tumor volume, high BED, and old age (log rank test; p = 0.0018, p = 0.021, and p = 0.004,

respectively) (Fig. 3a, b, c). Univariate Cox regression showed that old age, high initial tumor volume,

and high BED were significantly associated with tumor-volume increase (Table 2). However, only old

age remained statistically significant (HR: 5.51; 95% CI: 1.24–24.44; p = 0.025) in multivariate

analysis.

Correlation between tumor-volume increase and PTE

All PTEs were found in cases of meningiomas with volume increase during the short-term follow-up

(see online Supplementary Figure 5). Tumor-volume increase was significantly associated with PTE

development (log rank test; p = 0.003) (Figure 3d).

Discussion We found that an initial tumor volume more than about 7.9 cc, a prescription of BED > 45.9 Gy, and

age ≧65 years were predictive factors for tumor volume increase (>15% of baseline volume) during

short-term follow-up after LINAC-based radiation therapy. In the multivariate analysis, age was the

most-significant predictor of tumor-volume increase. In addition, we observed that all PTEs

developed in the group with tumor-volume increase.

Previous studies have reported volumetric changes in meningiomas after radiation treatment.[2,8–10] A

recent study showed that meningiomas that ultimately regress after SRS treatment tend to show a

volume-reduction response in the first 3 months of treatment.[5] In addition, by 6 months post-SRS,


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the group with volume increase ultimately showed initial tumor-volume growth above the baseline

volume. Thus, we believe that early imaging estimations of tumor volume may predict the tendency of

eventual tumor progression or regression. In addition, early tumor-volume assessment may be useful

for predicting long-term outcomes and help physicians improve the overall outcome after radiation

treatment in patients with meningioma.

In this study, age, radiation dose, and initial tumor volume were predictive risk factors for tumor-

volume increase during the short-term follow-up. Similar risk factors for tumor-volume increase after

radiation therapy for meningioma were reported.[7,11,12] However, to the best of our knowledge, this

study is one of the few studies that evaluates the volumetric change in meningiomas after an LINAC-

based radiation therapy. Although our study is limited due to its small scale and short-term follow-up

period, we tried to evaluate factors associated with an early dynamic volumetric change in

meningioma after radiation treatment. Semi-automated volumetric measurement using a relatively

accurate volume-measurement tool, such as the one used in this study,[13–15] may have increased the

reliability of the study.[13–15](13–15)

PTE develops after radiation treatment for benign meningioma in approximately 14%–25% of

patients.[16–18] The risk factors for PTE were similar to the risk factors for tumor-volume increase: age,

radiation dose, pre-existing edema, initial tumor volume, and tumor-brain contact interface area.[16–20]

We found that after radiation treatment, all PTEs developed in the group with early tumor-volume

increase. The arachnoid membrane and cerebral cortex formed by dense networks of neuronal and

glial processes are normally impermeable to fluid.[21] However, histologically, the interface between

the meningioma and brain has no intact arachnoid membrane.[22] Compression due to the growth of a

tumor on adjacent venous structures, leptomeninges, and the cerebral cortex may lead to an increase

in hydrostatic pressure.[23] In addition, radiation is known to destroy the tumor-brain contact

interface.[16] Both tumor-volume growth and radiation may cause further damage to an already

abnormal interface between the meningioma and cortex. Rapid tumor-volume expansion may lead to

a rapid increase in the disrupted tumor-brain contact interface area. This may induce and precipitate

direct transmission of edema fluid into the white matter, resulting in vasogenic edema.[16] Therefore,

we hypothesized that early rapid tumor growth (>15%) after radiation therapy for meningioma may be

associated with PTE. Loosening of the microstructure network and volume reduction of aging white

matter may increase the vulnerability for PTE, allowing direct transmissions of edema fluid into the

white matter.[24] In addition, high radiation doses may accelerate disruption of the tumor-brain contact

interface. Furthermore, a high initial tumor volume implies the presence of a large tumor-brain

contact interface area and high hydrostatic pressure before radiation. Therefore, precautions are

needed in old patients with early tumor-volume increase, a high prescription of radiation dosage, and

high initial tumor volume after radiation therapy for meningioma.

This study has a few limitations that need to be addressed. First, due to the retrospective nature of the

study, the length of follow-ups and the number of follow-up images for every meningioma varied

widely. Second, CT was used for follow-up in a few cases. Third, heterogeneity in tumor location and

absence of histological confirmation in many cases may have influenced the tumor-volume response

and PTE development after radiation therapy. Fourth, the small number of cases and short-term

follow-up periods may have reduced the statistical power and validation. Fifth, technical problems

may have occurred while measuring tumor volume due to the different slice thicknesses among the

imaging modalities and manual refinement error using the 3D Slicer.


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Conclusions In this study, high initial tumor volume, high BED for tumor, and old age were associated with early

tumor-volume increase after LINAC-based radiation treatment. Old age was the most-significant

predictive factor of tumor volume increase. We believe there may be a correlation between early

tumor-volume increase and PTE development post-radiation. Therefore, precautions should be taken

when treating patients with early tumor volume increase that exceeds 15%, especially in old age, with

high initial tumor volume, and high prescription dosages. Further large-scale and prospective long-

term follow-up studies are needed to confirm our findings.

Acknowledgements: None

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2. Mansouri A, Larjani S, Klironomos G, Laperriere N, Cusimano M, Gentili F, et al. Predictors of response to

Gamma Knife radiosurgery for intracranial meningiomas. J Neurosurg 2015;123(5):1294–300.

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Figure legends

Figure 1. Segmentation of meningioma with a 3D-reconstructed model using the GrowCut algorithm of the 3D Slicer and

calculation of the tumor volume (case number 24 and patient number 20)


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Figure 2. Graphical representation of tumor-volume percent change calculated using locally weighted scatter plot

smoothing curve and boxplot on the basis of the predictive variables: (a) Initial tumor volume > 7.876 cc. (b) Initial

tumor volume < 7.876 cc. (c) Biologically effective dose (45.9 Gy). (d) Age group (65 years)


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Figure 3. Cumulative hazard rate using Kaplan-Meier curve with a log-rank test.

(a) Association between initial tumor volume and tumor volume increase. (b) Association between biologically

effective dose and tumor-volume increase. (c) Association between age and tumor-volume increase. (d)

Association between tumor-volume increase and peritumoral edema occurrence


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Supplementary Figure 1. Treatment planning for meningioma using iPlan system in the NOVALIS Tx center at our

hospital (case number 24, patient number 20)


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Supplementary Figure 2. Volumetric comparison between the reference magnetic resonance image and simulation

computed tomography image (case number 19, patient number 15)


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Supplementary Figure 5. Peritumoral edema in 11 patients with tumor-volume increase.

(a) Patients with at least 2 follow-up images. (b) Patients with one follow-up image


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Supplementary Figure 6. Receiver operating characteristic curve for tumor-volume increase (>15%) based on (a) initial

tumor volume and (b) biologically effective dose for tumor (α/β = 10)

Table 1. Summary of characteristics of 32 meningiomas in 28 patients in the study.

Ca

se

no.

Patie

nt

no.

Se

x

Agea

(year

s)

Location

Initial

tumor

volu

meb

(cc)

Prior

resecti

on

WHO grade

Margi

nal

radiati

on

dose

(Gy)

Fracti

on

BE

D

(α/β

=

1

0

)

(

G

y

)

Tumo

r

volu

me

incre

ase

durin

g

follo

w-up

(>15

%)

Peri-

tumo

ral

edem

a

1 1 M 54 Jugular

foramen 15.85 No - 54.0 30

63.

72 No No

2 1 M 55 Caverno

us sinus 1.45 No - 24.0 3

43.

20 No No

3 1 M 55

Cerebell

ar

convexit

y

3.55 No - 24.0 3 43.

20 No No

4 2 F 50 Tentoria

l 2.91 No - 16.0 1

41.

60 No No

5 3 M 45 Parasagi

ttal 3.62 Yes

II

(Atypical) 14.0 1

33.

60 No No

6 4 F 56 Tentoria

l 18.47 Yes

I

(Fibrous) 30.0 5

48.

00 Yes No

7 5 F 49 Parasagi

ttal 7.88 Yes

I

(Transitiona

l)

28.5 5 44.

75 No No

8 6 M 73

Tubercul

um

sellae

7.78 Yes

I

(Meningoth

elial)

50.4 28 59.

47 No No


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9 7 F 52 Sphenoi

d ridge 25.03 Yes

I

(Angiomato

us)

50.4 28 59.

47 Yes No

10 8 M 70 Convexi

ty 13.79 Yes

I

(Meningoth

elial)

33.0 6 51.

15 No No

11 9 F 54

Cerebell

ar

convexit

y

1.04 Yes

I

(Fibroblasti

c)

15.5 1 39.

53 No No

12 10 F 55 Parasagi

ttal 5.81 Yes

I

(Transitiona

l)

14.0 1 33.

60 No No

13 11 F 74

Cerebell

ar

convexit

y

23.51 No - 27.5 5 42.

63 `Yes Yes

14 12 F 61 Convexi

ty 6.13 No - 25.0 5

37.

50 Yes No

15 12 F 61 Parasagi

ttal 5.45 No - 27.0 5

41.

58 No No

16 12 F 61 Preponti

ne 6.28 No - 27.0 5

41.

58 No No

17 13 F 70 Convexi

ty 1.22 No - 18.0 1

50.

40 Yes Yes

18 14 M 59 Caverno

us sinus 9.80 No - 32.5 5

53.

63 Yes No

19 15 F 74 Convexi

ty 9.39 No - 32.5 5

53.

63 Yes Yes

20 16 F 64 CPA 6.03 Yes

I

(Meningoth

elial)

30.0 5 48.

00 No No

21 17 F 36 Sphenoi

d ridge 0.37 No - 17.0 1

45.

90 No No

22 18 M 54 Preponti

ne 0.43 No - 17.0 1

45.

90 No No

23 19 F 64 Foramen

magnum 1.69 No - 30.0 30

33.

00 No No

24 20 M 75 Parasagi

ttal 34.33 No - 30.0 5

48.

00 Yes Yes

25 21 F 72 CPA 10.78 No - 30.0 5 48.

00 Yes No

26 22 F 69 Convexi

ty 2.37 No - 19.0 1

55.

10 Yes Yes

27 23 F 60 Parasagi

ttal 15.60 No - 34.0 10

45.

56 No No

28 24 F 59

Cerebell

ar

convexit

y

6.94 Yes I

(Fibrous) 34.0 10

45.

56 No No

29 25 F 62 Convexi

ty 2.57 No - 24.9 3

45.

57 Yes No

30 26 F 58 Convexi

ty 9.77 Yes

II

(Atypical) 31.0 5

50.

22 No No


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31 27 F 80 Parasagi

ttal 0.57 Yes

II

(Atypical) 29.0 5

45.

82 No No

32 28 F 36 Convexi

ty 0.43 Yes

II

(Atypical) 30.0 5

48.

00 No No

WHO, world health organization; BED, biologically effective dose; CPA, cerebellopontine angle aAge at radiosurgery or radiotherapy bGross tumor volume or clinical tumor volume


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Supplementary Table 1. Radiological modalities during follow-up in the study

Case

no.

Patient

no. Sex

Agea

(years)

Reference

image at

radiation

Follow-up image modalityb

(Days after radiosurgery or radiotherapy)

First Second Third Forth Fifth Sixth Seventh

1 1 M 54 MRI MRI

(110)

MRI

(199)

MRI

(382)

MRI

(738)

MRI

(763)

MRI

(846)

MRI

(895)

2 1 M 55 MRI MRI

(356)

MRI

(381)

MRI

(464)

MRI

(513)

3 1 M 55 MRI MRI

(356)

MRI

(381)

MRI

(464)

MRI

(513)

4 2 F 50 MRI MRI

(102)

5 3 M 45 MRI MRI

(120)

MRI

(372)

6 4 F 56 MRI MRI

(120)

MRI

(334)

MRI

(536)

7 5 F 49 MRI MRI

(90)

MRI

(190)

MRI

(556)

8 6 M 73 MRI MRI

(154)

MRI

(336)

MRI

(715)

9 7 F 52 MRI MRI

(201)

MRI

(385)

MRI

(764)

10 8 M 70 MRI CT

(194)

MRI

(377)

11 9 F 54 MRI MRI

(93)

12 10 F 55 MRI MRI

(180)

13 11 F 74 MRI MRI

(116)

MRI

(232)

MRI

(319)

MRI

(723)

14 12 F 61 MRI MRI

(235)

15 12 F 61 MRI MRI

(235)

16 12 F 61 MRI MRI

(235)

17 13 F 70 MRI MRI

(110)

MRI

(487)

18 14 M 59 MRI MRI

(176)

MRI

(548)

19 15 F 74 MRI MRI

(92)

CT

(156)

20 16 F 64 MRI CT

(106)

CT

(474)

21 17 F 36 MRI MRI

(385)

22 18 M 54 MRI MRI

(183)

23 19 F 64 MRI MRI

(224)

24 20 M 75 MRI MRI CT


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(40) (89)

25 21 F 72 MRI CT

(163)

26 22 F 69 MRI MRI

(120)

27 23 F 60 MRI CT

(154)

28 24 F 59 MRI CT

(332)

29 25 F 62 MRI MRI

(193)

30 26 F 58 MRI MRI

(127)

31 27 F 80 MRI CT

(92)

32 28 F 36 MRI CT

(112)

MRI, magnetic resonance imaging; CT, Computed tomography aAge at radiosurgery or radiotherapy bAll image modalities were performed with contrast enhancement

Supplementary Table 2. Variations in tumor volume during follow-up in the study

Case

no.

Patient

no. Sex

Agea

(years)

Follow-up tumor volume (cc)

(Days after radiosurgery or radiotherapy)

Reference

(0) First Second Third Forth Fifth Sixth Seventh

1 1 M 54 15.85 10.73

(110)

8.34

(199)

5.56

(382)

3.27

(738)

2.98

(763)

2.25

(846)

1.55

(895)

2 1 M 55 1.45 0.21

(356)

0.21

(381)

0.09

(464)

0.16

(513)

3 1 M 55 3.55 0.73

(356)

0.77

(381)

0.81

(464)

0.88

(513)

4 2 F 50 2.91 2.86

(102)

5 3 M 45 3.62 2.39

(120)

1.49

(372)

6 4 F 56 18.47 17.62

(120)

22.92

(334)

18.87

(536)

7 5 F 49 7.88 6.17

(90)

5.80

(190)

4.58

(556)

8 6 M 73 7.78 7.73

(154)

7.33

(336)

5.51

(715)

9 7 F 52 25.03 31.74

(201)

20.94

(385)

17.69

(764)

10 8 M 70 13.79 6.82

(194)

6.46

(377)

11 9 F 54 1.04 0.93

(93)

12 10 F 55 5.81 4.35

(180)

13 11 F 74 23.51 23.25

(116)

27.05

(232)

31.09

(319)

27.01

(723)


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14 12 F 61 6.13 7.69

(235)

15 12 F 61 5.45 6.06

(235)

16 12 F 61 6.28 7.04

(235)

17 13 F 70 1.22 1.51

(110)

1.16

(487)

18 14 M 59 9.80 12.51

(176)

11.20

(548)

19 15 F 74 9.39 9.51

(92)

10.89

(156)

20 16 F 64 6.03 5.65

(106)

5.72

(474)

21 17 F 36 0.37 0.23

(385)

22 18 M 54 0.43 0.30

(183)

23 19 F 64 1.69 0.77

(224)

24 20 M 75 34.33 37.07

(40)

42.09

(89)

25 21 F 72 10.78 13.26

(163)

26 22 F 69 2.37 2.89

(120)

27 23 F 60 15.60 14.98

(154)

28 24 F 59 6.94 7.49

(332)

29 25 F 62 2.57 3.08

(193)

30 26 F 58 9.77 7.75

(127)

31 27 F 80 0.57 0.21

(92)

32 28 F 36 0.43 0.20

(112)

aAge at radiosurgery or radiotherapy


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