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Effective treatment for symptomatic brain tumours and arteriovenous malformationin children by radiosurgery with a rotating gamma system

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Life ScienceS
Volume 64 Number 3
Brain tumours are the second most common group
of tumours in children following only after hematologic
cancers. This group of diseases originates from an
abnormal proliferation of nerve cells, astrocytes,
dendritic cells, or neuroblastoma. Brain tumours may
also be secondary from many types of cancer elsewhere
in the body. Depending on the location, size, and
nature of the tumour, the primary treatment for a brain
tumour may be surgery, radiotherapy, or chemotherapy.
In addition, surgery is difficult to conduct in cases of
brainstem tumours or tumours in some other locations
because serious complications can occur. In those cases,
radiosurgery using a rotating gamma knife (RGK) is a
safe and effective option that has been proven in many
studies [1-3]. Meanwhile, brain AVM includes lesions
that are defined by the presence of arteriovenous (AV)
shunting through a nidus of coiled and tortuous vascular
connections that connect feeding arteries to draining
veins [4]. Brain AVM is considered congenital vascular
lesions that can be present at any age. AVM was reported
to have a higher rate of rupture than in adults [5]. RGK
radiosurgery is one of the most effective treatment
methods for this disease, which has been known for a
long time [6].
Today, along with advances in medicine, many new
types of radiotherapy machines and methods have been
introduced to focus the dose on lesions while minimizing
the radiation dose to surrounding healthy tissues. Since
then, radiation therapy for the treatment of brain tumours
and AVM in children has been increasingly studied.
Radiation therapy plays an important role especially
for patients with large tumours, deep tumour sites, or
tumours on important organs such as the brainstem,
ventricles, etc., which are all very difficult places to
perform surgery. Gamma knife radiosurgery (GKRS) has
been used by Swedish professor Lar Leksell to treat brain
ours since 1968 with very good results. The gamma
knife system used by Lar
Leksell at that time contained
201 sources of Cobalt-60 arranged on a spherical hood
containing directional envelopes. These radiation sources
Effective treatment for symptomatic brain tumours and arteriovenous
in children by radiosurgery with a rotating gamma system
Khoa Mai Trong
, Phuong Pham Cam
, Luan Nguyen Duc
, Hung Nguyen Quang
Phuong Dao Manh
, Thai Pham Van
Hanoi Medical University
The Nuclear Medicine and Oncology Centre, Bach Mai Hospital
Received 1 October 2021; accepted 3 December 2021
Corresponding author: Email: [email protected]
To assess the effectiveness of radiosurgery with a rotating gamma system (RGS) for paediatric brain tumours
and arteriovenous malformation (AVM), this work was carried out on 123 patients with brain tumours or
AVM received radiosurgery at Bach Mai hospital. The median dose was 13 Gy from a range of 8 to 20 Gy.
Endpoints include the effects of increased intracranial pressure, seizures, hemiplegia, and tumour size on the
syndrome. Results exhibited that the percentages of patients with complete response, partial response, and
disease progression out of 59 patients with headache accounted for 11.9, 69.5, and 18.6%, respectively. Of the
20 patients with seizures, 30% had complete response, 65% partial response, and 5% stable disease. Regarding
brain tumour size, 9 months after treatment, those with complete response, partial response, stable disease,
and disease progression made up 18.7, 50.4, 14.6, and 16.3% of the total patients, respectively. There was no
statistically significant effect of radiation dose on the results. This study showed a high percentage of children
with brain tumours and AVM undergoing radiosurgery with a RGS had symptomatic responses after treatment.
arteriovenous malformation, brain tumours in children, headache, hemiplegia, radiosurgery,
rotating gamma system, seizures, symptom relief.
Classification number:
DOI : 10.31276/VJSTE.64(3).44-48
Life ScienceS
Volume 64 Number 3
were directed through directional gates so that the beams
were focused on the pathological point in the brain [7,
8]. The RGS uses 30 sources of Cobalt-60 symmetrically
distributed around a hemisphere between latitude angles
of 13 to 43º as measured from the sagittal plane. The
sources within the single housing helmet rotate at a speed
of approximately 2 to 4 rotations per minute. Inside the
source hemisphere, a concentric collimating hemisphere
is co-rotating with the sources and exposes the desired
beam diameter such as 4, 8, 14, or 18 mm. The rotating
sources of RGS simulate an infinite number of beams and
promote extremely high target-to-surface dose ratios [9].
Since July 2007, the Nuclear Medicine and Oncology
Centre at Bach Mai hospital has used the Gamma ART
6000, an American radiosurgery system, which is a
hybrid with features of both the gamma knife and LINAC
radiosurgery systems to treat brain tumours and AVM.
More than 6000 patients, including children, with brain
tumours and intracranial diseases have been treated with
the RGK. This group has conducted a thesis to assess the
role of this treatment method in the treatment of brain
tumours and intracranial diseases in children.
Patients and study methods
From July 2007 to December 2020, 123 paediatric
patients (≤15 years old) included in this prospective
interventional study received radiosurgery for brain
and intracranial diseases
with RGS at the Nuclear
Medicine and Oncology Centre, Bach Mai hospital,
The patients had symptomatic tumours of the brain
or AVM. Their lesions had specific features on magnetic
resonance imaging (MRI), computed tomography (CT),
or magnetic resonance spectroscopy (MRS) [10, 11].
Specifically, the lesions had a maximum diameter of 3
cm, and in a few cases, we accepted tumours with sizes
of no greater than 5 cm with no severe comorbidity. The
ages of the patients were no greater than 15 years old.
The patients were without pregnancy or lactation. There
were indications for the subjects to be treated with RGK
given by the Hospital Medical Council. All patients gave
consent to join in the study.
In this study, we used the Gamma ART 6000, an
American Radiosurgery system. We gave patients a
single dose of radiosurgery from 8 to 20 Gy. The dose was
defined to the outer margin of the tumour representing
50% isodose. The radiation oncologists decided the
specific radiation dose for each patient. We then grouped
patients according to the treated dose with a threshold
of 14 Gy (median value of the range from 8 to 20 Gy)
to test whether the radiation dose affected the treatment
The primary endpoint was a response in clinical
symptoms in a follow-up period of 9 months after
treatment, which included the syndrome of increased
intracranial pressure, seizures, and hemiplegia. When
compared to symptoms before treatment, the patient
might have either complete response (complete relief of
symptoms), partial response (partial relief of symptoms),
stable disease (no change in symptoms), or progressive
disease (an increase in symptoms). Another study
endpoint was the change in the size of tumours on the
MRI scans after 9 months.
The data were coded and analysed by SPSS 16.0
using statistical algorithms. A p-value of less than 0.05
was considered significant.
Patient characteristics
Out of 123 paediatric patients that met the criteria
in this study, 45 patients were female (36.6%) and 78
patients were male (63.4%). The median age was 10
years in a range from 4 to 15 years. Diagnosis beginning
with the highest rate: astrocytoma in 29 patients (23.6%),
AVM in 20 patients (16.3%), pineal gland tumour
in 18 patients (14.6%), and brainstem tumour in 14
patients (11.4%). The tumour was in the temporal lobe
in 21 patients (17.1%), in the frontal lobe in 20 patients
(16.3%), in the
pineal gland in 18 patients (14.6%), and
other positions accounted for less percentage.
Clinical symptoms prior to RGK
The clinical symptoms of the 123 patients are
shown in Table 1. Prior to RGS irradiation, 59 patients
(48%) had a significant headache, 20 patients (16.3%)
had significant seizures, and 17 patients (13.8%) had
significant hemiplegia.
Table 1. Clinical symptoms prior to RGK.
Number of patients
Proportion (%)
Increased intracranial pressure
Puberty early
Double vision
Blurred vision
Drooping eyelids
Cerebellum syndrome
Absence of consciousness

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