• Manjul Tripathi, Rajashekhar Rekhapalli, Aman Batish, Narendra Kumar, Arun S Oinam, Chirag K Ahuja, Harsh Deora, Ashish Aggarwal, Sandeep Mohindra, Parwinder Kaur, Rupinder Kaur, Sandeep Bhatt, and Jenil Gurnani.
• Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India. Electronic address: drmanjultripathi@gmail.com.
• World Neurosurg. 2019 Nov 1; 131: e136-e148.

BackgroundWhile multisession dose fractionated Gamma Knife radiosurgery (DFGKS) is common, its use has never been described for jugular paragangliomas (JP), which are notoriously difficult to treat.ObjectiveTo define efficacy, safety, and complication profile of DFGKS in 2 or 3 consecutive sessions for the treatment of a cohort of 10 cases of JP.MethodsBetween 2012 and 2017, 10 patients with JP were treated with DFGKS in 2 or 3 sessions, because it was not safe to treat the lesion in a single session because of the large volume or proximity to organs at risk. The small to medium-sized JP are treated with 16-22 Gy radiation, but the large-volume JP were treated with 23-25 Gy radiation dose. The Leksell G frame was kept in situ during the whole procedure. The tumor volumes on pretreatment and posttreatment imaging were compared, using the Leksell Gamma Plan treatment plan software to assess tumor progression. The patients were regularly evaluated for their clinical outcome with radiologic correlation.ResultsThe mean radiologic follow-up was 39 months (range, 12-78 months). The mean marginal dose for 3 fractions and 2 fractions was 7.64 Gy at 50% and 11.2 Gy at 50%, respectively. The mean tumor size was 29.9 cm3 (range, 9.95-47.63 cm3) at treatment and 21.9 cm3 (range, 8.83-37.5 cm3) at follow-up (suggestive of 26.7% reduction). Tumor control was achieved in all patients (100%). Of 110 potential neurologic problems (signs/symptoms) evaluated (11 in each patient), 56 (50.9%) were present preoperatively. Of them, 27 (48.2%) improved and 29 (51.8%) stabilized after treatment. There were 2 new-onset neurologic problems (of 110, 1.8%) attributable to treatment (new-onset headache and spinal accessory paresis). No patient had any permanent neurologic deterioration.ConclusionsDFGKS for large-volume JP leads to acceptable progression-free survival, tumor control rate, and symptomatic improvement. It may be preferred to surgery or fractionated radiotherapy given its better safety, efficacy, and complication profile.Copyright © 2019 Elsevier Inc. All rights reserved.

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