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• W1981656091 abstract "The past 3 decades have witnessed increasing interest in the use of stereotactic irradiation as an alternative and as an adjunct to microsurgical resection, embolization, and observation in the management of intracranial arteriovenous malformations (AVMs). The report by Flickinger et nl. (7 ), in this special issue of the journal that explores the response of vascular abnormalities to radiotherapy, provides an opportunity to assess the objectives and accomplishments of clinical research in this area. Arteriovenous malformations, whether congenital or acquired (e.g., secondary to trauma), represent vascular anomalies characterized by pathologic shunting of blood from the arterial to the venous system and are composed of feeding arteries, a nidus (i.e., shunted vessels), and draining veins. Indications for the treatment of AVMs with radiosurgery have included lesions that recur or persist following surgery, lesions that are deemed inoperable (an evolving term that previously implied diffuse involvement of a vital region of the brain [Spetzler Martin grade VI]), patient preference, and patient infirmity. Advantages associated with radiosurgical treatment of AVMs include its relatively noninvasive nature, negligible rates of mortality, and high rates of occlusion (60%-90% within 2 years of treatment). The primary drawbacks of radiosurgical treatment of AVMs pertain to the potential morbidities associated with the deposition of high radiation (RT) doses within the adjacent brain parenchyma and the relatively long latency before full protection against repeat hemorrhage is conferred. Despite the fact that nearly 10,000 patients have been treated with radiosurgery for AVMs, few RT dose-response data have been presented for AVM obliteration. In addition. available reports of dose-response generally lack information on volume of the lesions treated, use assorted conventions to quote dose at varying isodose lines, and cannot standardize target definitions because of inconsistent interpretation of imaging studies. To address this inconsistency, the group from the University of Pittsburgh looked specifically at the end point of nidus obliteration within the target volume. In so doing, they generated a sigmoid dose-response for the lesions that they have treated. The influence of target volume on both nidus obliteration and complications is difficult to elicit from the literature. Contradictory conclusions have been reported by investigators who attempted to correlate response with the actual target volume (3, 5. 12). Since the initial radiosurgical treatment of an AVM by Kjellberg in 1965, the convention has been to tailor dose inversely to volume (13). Consequently, higher doses have often been a surrogate for smaller nidus volumes. Although the investigators at the University of Pittsburgh used a moderately broad range of dose, they tended to deal with smaller lesions than the other centers cited in their report (References 5, 6, 11. and 27 of their manuscript), Thus. the authors’ cautionary note that even the dose-response that they propose is applicable only across a relatively small range of target volumes should be underscored. The Pittsburgh group concluded that volume did not independently influence in-field obliteration, Because only a small number of events (i.e., failures) have been seen at the University of Pittsburgh, the decision to evaluate only three factors in the multivariate analysis (~i.e., D,,,, D,i,, and volume) is statistically sound. Notwithstanding, the reader is left to wonder about potential confounding by other variables [such as those included in their multivariate analysis of variance (MANOVA) comparison of group characteristics]. These factors may have contributed to the RT dose and target volume selection for these lesions in a manner that is difficult to control for in a retrospective analysis. To include all of the factors from the MANOVA, however. would have diluted the strength of the regression analysis, and therefore, several potentially important parameters (e.g.. isodose. number of isocenters, number of bleeds) were omitted from the multivariate model. Even though this is one of the largest series in the literature for AVMs. it is still a relatively small study for dose-response analysis because" @default.
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• W1981656091 title "Can we disentangle dose from volume in the radiosurgical management of arteriovenous malformations?" @default.
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• W1981656091 doi "https://doi.org/10.1016/s0360-3016(96)00437-3" @default.
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