Research Article

Assessment of Multimodality Imaging for Target Definition of Intracranial Chondrosarcomas

Selcuk Demiral*, Ferrat Dincoglan, Omer Sager and Murat Beyzadeoglu

Department of Radiation Oncology, University of Health Sciences, Turkey

Submission:January 07, 2021; Published: March 02, 2021

*Corresponding Address: Dr. Selcuk Demiral, Department of Radiation Oncology, University of Health Sciences Turkey

How to cite this article: Selcuk D, Ferrat D, Omer S, Murat B. Assessment of Multimodality Imaging for Target Definition of Intracranial Chondrosarcomas. Canc Therapy & Oncol Int J. 2021; 18(2): 555981. DOI:10.19080/CTOIJ.2021.18.555981

Abstract

Objective: Radiation therapy (RT) may be considered as an adjunctive treatment or in the setting of unresectability or inoperability for intracranial chondrosarcoma management. Target definition constitutes a prominent part of safe and efficacious management with irradiation. Herein, we evaluated multimodality imaging for target definition for radiotherapeutic management of intracranial chondrosarcomas.

Materials and methods: In this study, we assessed target definition with multimodality imaging through incorporation of MRI for patients with intracranial chondrosarcoma. Either CT-simulation images only or fused CT and MR images were utilized for target volume definition. Comparative evaluation was made for target volume designation with CT only and by incorporation of CT-MR fusion.

Results: Target definition by CT-only imaging and by CT-MR fusion based imaging was assessed with comparison of both approaches. Ground truth target volume outlined by input from board-certified radiation oncologists following meticulous evaluation, thorough consideration, collaboration, colleague peer review, and final consensus was found to be identical with target definition by use of CT-MR fusion based imaging in this study.

Conclusion: Intracranial chondrosarcomas are relatively rare but locally aggressive tumors requiring intensive management. Irradiation may have a role in management either as an adjunctive or definitive therapeutic modality. Multimodality imaging with incorporation of MRI in target definition process may be considered given the importance of proper and precise targeting of these tumors for successful radiotherapeutic management. Clearly, there is need for further studies to shed light on this issue.

Keywords: Irradiation; Chondrosarcoma; Intracranial; Magnetic resonance imaging (MRI)

Abbrevations: RT: Radiation Therapy; CFRT: Conventionally Fractionated Radiation Therapy; SRS: Stereotactic Radiosurgery; FSRT: Fractionated Stereotactic Radiation Therapy; HFSRT: Hypofractionated Stereotactic Radiation Therapy; SABR: Stereotactic Ablative Body ; LINAC : Linear Accelerator; BART: Breathing Adapted Radiation Therapy; ART: Adaptive Radiation Therapy; IMRT: Intensity Modulated Radiation Therapy

Introduction

While chondrosarcoma is among the frequent primary bone malignancies, intracranial chondrosarcomas are rare tumors accounting for approximately 0.15% of all intracranial neoplasms [1,2]. Patient symptomatology depends on lesion location and association with eloquent brain areas. Intracranial chondrosarcomas may be localized at the skull base in close vicinity of vital neurovascular structures. Surgery is a principal mode of management for these tumors, however, their critical location may prevent complete surgical resection due to concerns about preservation of neurological functions and quality of life. Within this context, irradiation may be considered as an adjunctive treatment or in the setting of unresectability or inoperability. The typically radioresistant nature of these tumors may require the delivery of high radiation doses to achieve optimal therapeutic outcomes, nevertheless, critical organ dose constraints should be taken into account to avoid radiation induced adverse effects. Irradiation in the forms of conventionally fractionated radiation therapy (CFRT) or radiosurgery as Stereotactic Radiosurgery (SRS), Fractionated Stereotactic Radiation Therapy (FSRT), Hypofractionated Stereotactic Radiation Therapy (HFSRT), and Stereotactic Ablative Body Radiotherapy (SABR) may be utilized as valuable treatment modalities in the therapeutic armamentarium with encouraging outcomes for management of a plethora of central nervous system (CNS) disorders and for several other benign and malignant neoplasms [3-24]. In the context of intracranial chondrosarcoma management, several studies have suggested the utility of irradiation with contemporary radiotherapeutic approaches including particle therapy with carbon ion and protons [25-29]. Toxicity profile of irradiation is a critical aspect of management with RT considering the critical location of chondrosarcomas in the vicinity of important neurovascular structures. Thus, target definition for precise irradiation constitutes a prominent part of safe and efficacious management with irradiation. Herein, we evaluated multimodality imaging for target definition for radiotherapeutic management of intracranial chondrosarcomas.

Materials and methods

In this study, we assessed target definition with multimodality imaging through incorporation of MRI for patients with intracranial chondrosarcoma. Ground truth target volume serving as the reference to be used for actual treatment and comparison purposes was determined by radiation oncologists after meticulous assessment, colleague peer review, collaboration, and consequent consensus. Thorough individualized patient evaluation included consideration of lesion size, localization, symptoms, patient preferences, and contemplated outcomes and toxicity profile of radiotherapeutic treatment. CT-simulator (GE Lightspeed RT, GE Healthcare, Chalfont St. Giles, UK) was used in treatment simulation of patients for radiation treatment planning (RTP) at our tertiary referral institution. Planning CT images were acquired and sent to delineation workstation (SimMD, GE, UK) for contouring of treatment volumes and nearby normal tissues. Either CT-simulation images only or fused CT and MR images were utilized for target volume definition. Comparative evaluation was made for target volume designation with CT only and by incorporation of CT-MR fusion. Determination of ground truth target volume was executed by radiation oncologists following meticulous assessment, collaboration, colleague peer review and final consensus to be used for actual treatment as well as for comparative evaluation. Synergy (Elekta, UK) linear accelerator (LINAC) was utilized for precise treatment delivery accompanied by routinely incorporated Image Guided Radiation Therapy (IGRT) techniques available at our tertiary cancer center.

Results

Available treatment planning systems at our department were used for RTP. Encompassing of target volume with optimal critical organ protection was prioritized to achieve an optimal therapeutic ratio. Synergy (Elekta, UK) LINAC was used for accurate and precise delivery of irradiation. Target definition by CT-only imaging and by CT-MR fusion based imaging was assessed with comparison of both approaches. Ground truth target volume outlined by input from board-certified radiation oncologists following meticulous evaluation, thorough consideration, collaboration, colleague peer review, and final consensus was found to be identical with target definition by use of CT-MR fusion based imaging in this study.

Discussion

Although relatively rare, intracranial chondrosarcomas may behave as locally aggressive tumors with preponderance for local recurrence. Irradiation by CFRT, radiosurgery, or particle therapy with incorporation of modern RT techniques may be used for optimal management of patients with intracranial chondrosarcoma. While irradiation may serve as an adjunctive therapy after incomplete surgical resection, definitive radiotherapeutic management may also be considered in the setting of unresectability or inoperability. The discipline of radiation oncology has experienced substantial progress recently with adoption of contemporary technologies, adaptive irradiation strategies and excellent treatment delivery techniques including incorporation of automatic segmentation methods, molecular imaging, Adaptive Radiation Therapy (ART), Intensity Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), Breathing Adapted Radiation Therapy (BART), and stereotactic irradiation with SRS, FSRT, and SABR [30-40]. Contemporary therapeutic strategies such as radiosurgical applications have great potential for focused and precise irradiation by means of rigid immobilization and may confer progress in accuracy of irradiation, however, target definition gains further importantance when relatively higher radiation doses are administered in a single or few treatment fractions. Precision and accuracy in target definition is an indispensable component in state of the art radiotherapeutic management of intracranial chondrosarcomas. Designation of larger than actual target volumes may profoundly enhance exposure of surrounding critical organs which may potentially translate into adverse radiation effects and deterioration in quality of life of affected patients. From a different standpoint, targeting of an improper treatment volume may result in geographical miss and subsequent recurrence. Nevertheless, determining the exact localization of intracranial chondrosarcomas with optimal target definition by use of multimodality imaging and IGRT techniques may offer improved precision in radiotherapeutic management of these tumors. Indeed, several other studies have also addressed the utility of multimodality imaging for target definition [41-61]. Within this context, the current study may add to the existing literature by addressing of multimodality imaging for target definition in intracranial chondrosarcoma RTP.

Conclusion

In conclusion, Intracranial chondrosarcomas are relatively rare but locally aggressive tumors requiring intensive management. Irradiation may have a role in management either as an adjunctive or definitive therapeutic modality. Multimodality imaging with incorporation of MRI in target definition process may be considered given the importance of proper and precise targeting of these tumors for successful radiotherapeutic management. Clearly, there is need for further studies to shed light on this issue.

References

1. Bloch OG, Jian BJ, Yang I, Han SJ, Aranda D,et. al. (2009) A systematic review of intracranial chondrosarcoma and survival. J Clin Neurosci 16(12): 1547-1451.
2. Cianfriglia F, Pompili A, Occhipinti E (1978) Intracranial malignant cartilaginous tumours. Report of two cases and review of literature. Acta Neurochir (Wien) 45(1-2): 163-175.
3. Sirin S, Oysul K, Surenkok S, Sager O, Dincoglan F, et al. (2011) Linear accelerator-based stereotactic radiosurgery in recurrent glioblastoma: A single center experience. Vojnosanit Pregl 68: 961-966.
4. Dincoglan F, Beyzadeoglu M, Sager O, Oysul K, Sirin S et al. (2012) Image-guided positioning in intracranial non-invasive stereotactic radiosurgery for the treatment of brain metastasis. Tumori 98: 630-635.
5. Dincoglan F, Sager O, Gamsiz H, Uysal B, Demiral S, et al. (2012) Stereotactic radiosurgery for intracranial tumors: A single center experience. Gulhane Med J 54: 190-198.
6. Demiral S, Beyzadeoglu M, Uysal B, Oysul K, Kahya YE, et al., (2013)  Evaluation of stereotactic body radiotherapy (SBRT) boost in the management of endometrial cancer. Neoplasma 60: 322-327.
7. Dincoglan F, Beyzadeoglu M, Sager O, Uysal B, Demiral S, et al. (2013) Evaluation of linear accelerator-based stereotactic radiosurgery in the management of meningiomas: A single center experience. J BUON 18: 717-722.
8. Sager O, Beyzadeoglu M, Dincoglan F, Demiral S, Uysal B, et al. (2013) Management of vestibular schwannomas with linear accelerator-based stereotactic radiosurgery: a single center experience. Tumori99: 617-622.
9. Sager O, Beyzadeoglu M, Dincoglan F, Gamsiz H, Demiral S, et al. (2014) Evaluation of linear accelerator-based stereotactic radiosurgery in the management of glomus jugulare tumors. Tumori 100: 184-188.
10. Dincoglan F, Sager O, Gamsiz H, Uysal B, Demiral S, et al. (2014) Management of patients with ≥ 4 brain metastases using stereotactic radiosurgery boost after whole brain irradiation. Tumori 100(3): 302-306.
11. Sager O, Beyzadeoglu M, Dincoglan F, Uysal B, Gamsiz H, et al. (2014) Evaluation of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) for cerebral cavernous malformations: A 15-year single-center experience. Ann Saudi Med 34: 54-58.
12. Gamsiz H, Beyzadeoglu M, Sager O, Dincoglan F, Demiral S, et al. (2014) Management of pulmonary oligometastases by stereotactic body radiotherapy. Tumori 100: 179-183.
13. Demiral S, Beyzadeoglu M, Sager O, Dincoglan F, Gamsiz H, et al. (2014) Evaluation of linear accelerator (linac)-based stereotactic radiosurgery (srs) for the treatment of craniopharyngiomas. UHOD - Uluslararasi Hematoloji-Onkoloji Dergisi 24: 123-129.
14. Demiral S, Beyzadeoglu M, Sager O, Dincoglan F, Gamsiz H, et al. (2014) Evaluation of Linear Accelerator (Linac)-Based Stereotactic Radiosurgery (Srs) for the Treatment of Craniopharyngiomas. UHOD-Uluslararasi Hematoloji Onkoloji Dergisi 24(2): 123-129.
15. Dincoglan F, Beyzadeoglu M, Sager O, Demiral S, Gamsiz H, et al. (2015) Management of patients with recurrent glioblastoma using hypofractionated stereotactic radiotherapy. Tumori 101: 179-184.
16. Sager O, Dincoglan F, Beyzadeoglu M (2015) Stereotactic radiosurgery of glomus jugulare tumors: Current concepts, recent advances and future perspectives. CNS Oncol 4: 105-114.
17. Gamsiz H, Beyzadeoglu M, Sager O, Demiral S, Dincoglan F, et al. (2015) Evaluation of stereotactic body radiation therapy in the management of adrenal metastases from non-small cell lung cancer. Tumori 101: 98-103.
18. Demiral S, Dincoglan F, Sager O, Gamsiz H, Uysal B, et al. (2016) Hypofractionated stereotactic radiotherapy (HFSRT) for who grade I anterior clinoid meningiomas (ACM). Jpn J Radiol 34: 730-737.
19. Dincoglan F, Sager O, Demiral S, Uysal B, Gamsiz H, et al. (2017) Radiosurgery for recurrent glioblastoma: A review article. Neurol Disord Therap 1: 1-5.
20. Dincoglan F, Sager O, Demiral S, Gamsiz H, Uysal B, et al., (2019) Fractionated stereotactic radiosurgery for locally recurrent brain metastases after failed stereotactic radiosurgery. Indian J Cancer 56: 151-156.
21. Dincoglan F, Sager O, Uysal B, Demiral S, Gamsiz H, et al. (2019) Evaluation of hypofractionated stereotactic radiotherapy (HFSRT) to the resection cavity after surgical resection of brain metastases: A single center experience. Indian J Cancer 56: 202-206.
22. Dincoglan F, Beyzadeoglu M, Sager O, Demiral S, Uysal B, et al. (2020) A Concise Review of Irradiation for Temporal Bone Chemodectomas (TBC). Arch Otolaryngol Rhinol 6: 16-20.
23. Sager O, Beyzadeoglu M, Dincoglan F, Demiral S, Gamsiz H, et al. (2020) Multimodality management of cavernous sinus meningiomas with less extensive surgery followed by subsequent irradiation: Implications for an improved toxicity profile. J Surg Surgical Res 6: 56-61.
24. Beyzadeoglu M, Sager O, Dincoglan F, Demiral S, Uysal B, et al. (2020) Single Fraction Stereotactic Radiosurgery (SRS) versus Fractionated Stereotactic Radiotherapy (FSRT) for Vestibular Schwannoma (VS). J Surg Surgical Res 6: 62-66.
25. Uhl M, Mattke M, Welzel T, Oelmann J, Habl G, et al. (2014) High control rate in patients with chondrosarcoma of the skull base after carbon ion therapy: first report of long-term results. Cancer 120(10): 1579-1585.
26. Simon F, Feuvret L, Bresson D, Guichard JP, El Zein S, et al. (2018) Surgery and protontherapy in Grade I and II skull base chondrosarcoma: A comparative retrospective study. PLoS One 13(12): e0208786. 
27. Korten AG, ter Berg HJ, Spincemaille GH, van der Laan RT, Van de Wel AM. (1998) Intracranial chondrosarcoma: review of the literature and report of 15 cases. J Neurol Neurosurg Psychiatry 65(1): 88-92. 
28. Vasudevan HN, Raleigh DR, Johnson J, Garsa AA, Theodosopoulos PV, et al., (2017) Management of Chordoma and Chondrosarcoma with Fractionated Stereotactic Radiotherapy Front Surg 4: 35.
29. Kano H, Niranjan A, Lunsford LD. (2019) Radiosurgery for Chordoma and Chondrosarcoma. Prog Neurol Surg 34:207-214. 
30. Sager O, Dincoglan F, Gamsiz H, Demiral S, Uysal B, et al. (2012) Evaluation of the impact of integrated [18f]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography imaging on staging and radiotherapy treatment volume definition of nonsmall cell lung cancer. Gulhane Med J 54: 220-227.
31. Sager O, Beyzadeoglu M, Dincoglan F, Oysul K, Kahya YE, et al. (2012) Evaluation of active breathing control-moderate deep inspiration breath-hold in definitive non-small cell lung cancer radiotherapy. Neoplasma 59: 333-340.
32. Sager O, Beyzadeoglu M, Dincoglan F, Oysul K, Kahya YE, et al., (2012) The Role of Active Breathing Control-Moderate Deep Inspiration Breath-Hold (ABC-mDIBH) Usage in non-Mastectomized Left-sided Breast Cancer Radiotherapy: A Dosimetric Evaluation UHOD - Uluslararasi Hematoloji-Onkoloji Dergisi 22: 147-155.
33. Dincoglan F, Beyzadeoglu M, Sager O, Oysul K, Kahya YE, et al. (2013) Dosimetric evaluation of critical organs at risk in mastectomized left-sided breast cancer radiotherapy using breath-hold technique. Tumori 99: 76-82.
34. Ozsavas EE, Telatar Z, Dirican B, Sager O, Beyzadeoglu M (2014) Automatic segmentation of anatomical structures from CT scans of thorax for RTP. Comput Math Methods Med2014: 472890.
35. Sager O, Beyzadeoglu M, Dincoglan F, Demiral S, Uysal B, et al. (2015) Adaptive splenic radiotherapy for symptomatic splenomegaly management in myeloproliferative disorders. Tumori 101(1): 84-90.
36. Sager O, Dincoglan F, Uysal B, Demiral S, Gamsiz H, et al. (2017) Splenic Irradiation: A Concise Review of the Literature. J App Hem Bl Tran 1: 101.
37. Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, et al. (2019) Breathing adapted radiation therapy for leukemia relapse in the breast: A case report. World J Clin Oncol 10: 369-374.
38. Sager O, Dincoglan F, Uysal B, Demiral S, Gamsiz H, et al. (2018) Evaluation of adaptive radiotherapy (ART) by use of replanning the tumor bed boost with repeated computed tomography (CT) simulation after whole breast irradiation (WBI) for breast cancer patients having clinically evident seroma. Jpn J Radiol 36: 401-406. 
39. Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, et al. (2019) Utility of Molecular Imaging with 2-Deoxy-2-[Fluorine-18] Fluoro-DGlucose Positron Emission Tomography (18F-FDG PET) for Small Cell Lung Cancer (SCLC): A Radiation Oncology Perspective. Curr Radiopharm 12: 4-10.
40. Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, et al. (2020) Adaptive radiation therapy of breast cancer by repeated imaging during irradiation. World J Radiol 12(5): 68-75.
41. Omer S, Selcuk D, Ferrat D, Murat B (2020) Assessment of Target Volume Definition for Irradiation of Hemangiopericytomas: An Original Article. Canc Therapy & Oncol Int J 17(2): 555959.
42. Omer Sager, Ferrat Dincoglan, Selcuk Demiral, Murat Beyzadeoglu. (2020) Evaluation of Treatment Volume Determination for Irradiation of chordoma: an Original Article. International Journal of Research Studies in Medical and Health Sciences 5 (10): 3-8
43. Dincoglan F, Beyzadeoglu M, Demiral S, Sager O (2020) Assessment of Treatment Volume Definition for Irradiation of Spinal Ependymomas: an Original Article. ARC Journal of Cancer Science 6: 1-6.  
44. Beyzadeoglu M, Dincoglan F, Demiral S, Sager O (2020) Target Volume Determination for Precise Radiation Therapy (RT) of Central Neurocytoma: An Original Article. International Journal of Research Studies in Medical and Health Sciences 5: 29-34.
45. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2020) Target Volume Definition for Stereotactic Radiosurgery (SRS) Of Cerebral Cavernous Malformations (CCMs). Canc Therapy & Oncol Int J 15: 555917.
46. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2020) Evaluation of Target Volume Determination for Irradiatıon of Pilocytic Astrocytomas: An Original Article. ARC Journal of Cancer Science 6: 1-5.
47. Demiral S, Beyzadeoglu M, Dincoglan F, Sager O (2020) Assessment of Target Volume Definition for Radiosurgery of Atypical Meningiomas with Multimodality Imaging. Journal of Hematology and Oncology Research 3: 14-21.
48. Demiral S, Beyzadeoglu M, Dincoglan F, Sager O (2020) Evaluation of Radiosurgery Target Volume Definition for Tectal Gliomas with Incorporation of Magnetic Resonance Imaging (MRI): An Original Article. Biomedical Journal of Scientific & Technical Research (BJSTR) 27: 20543-20547.
49. Beyzadeoglu M, Dincoglan F, Sager O, Demiral S (2020) Determination of Radiosurgery Treatment Volume for Intracranial Germ Cell Tumors (GCTS). Asian Journal of Pharmacy, Nursing and Medical Sciences 8: 18-23.
50. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2020) Radiosurgery Treatment Volume Determination for Brain Lymphomas with and without Incorporation of Multimodality Imaging. Journal of Medical Pharmaceutical and Allied Sciences 9: 2398-2404.
51. Dincoglan F, Demiral S, Sager O, Beyzadeoglu M (2020) Utility of Multimodality Imaging Based Target Volume Definition for Radiosurgery of Trigeminal Neuralgia: An Original Article. Biomed J Sci & Tech Res 26: 19728-19732.
52. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2019) Multimodality Imaging for Radiosurgical Management of Arteriovenous Malformations. Asian Journal of Pharmacy, Nursing and Medical Sciences 7: 7-12.
53. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2019) Assessment of target definition based on Multimodality imaging for radiosurgical Management of glomus jugulare tumors (GJTs). Canc Therapy & Oncol Int J 15: 555909.
54. Sager O, Dincoglan F, Demiral S, Gamsiz H, Uysal B, et al. (2019) Utility of Magnetic Resonance Imaging (Imaging) in Target Volume Definition for Radiosurgery of Acoustic Neuromas. Int J Cancer Clin Res 6: 119.
55. Beyzadeoglu M, Sager O, Dincoglan F, Demiral S (2019) Evaluation of Target Definition for Stereotactic Reirradiation of Recurrent Glioblastoma. Arch Can Res 7: 3.
56. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2019) Incorporation of Multimodality Imaging in Radiosurgery Planning for Craniopharyngiomas: An Original Article. SAJ Cancer Sci 6: 103.
57. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2019) Evaluation of Radiosurgery Target Volume Determination for Meningiomas Based on Computed Tomography (CT) And Magnetic Resonance Imaging (MRI). Cancer Sci Res Open Access 5: 1-4.
58. Sager O, Dincoglan F, Demiral S, Gamsiz H, Uysal B, et al. (2019) Evaluation of the Impact of Magnetic Resonance Imaging (MRI) on Gross Tumor Volume (GTV) Definition for Radiation Treatment Planning (RTP) of Inoperable High Grade Gliomas (HGGs). Concepts in Magnetic Resonance Part A 2019, 4282754.
59. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2019) Assessment of Computed Tomography (CT) And Magnetic Resonance Imaging (MRI) Based Radiosurgery Treatment Planning for Pituitary Adenomas. Canc Therapy & Oncol Int J 13: 555857.
60. Demiral S, Dincoglan F, Sager O, Uysal B, Gamsiz H, et al. (2018) Contemporary Management of Meningiomas with Radiosurgery. Int J Radiol Imaging Technol 80: 187-190.\
61. Demiral S, Sager O, Dincoglan F, Uysal B, Gamsiz H, et al. (2018) Evaluation of Target Volume Determination for Single Session Stereotactic Radiosurgery (SRS) of Brain Metastases. Canc Therapy & Oncol Int J 12: 555848.