Sheehan JP, Gerszten PC. Controversies in Stereotactic Radiosurgery: Best Evidence Recommendations. Thieme; 2014; 270 pp; 130 illustrations; $129.99
This book reviews a number of selected topics in stereotactic radiosurgery of both the brain and the spine, with the objective of reviewing evidence that supports specific radiosurgical treatments. Somewhat more than half of the book covers cranial topics, and the other half covers spinal topics. There are 39 chapters organized in sections; some chapters are paired in presenting opposing positions on specific topics.
A brief introductory chapter includes tables of classification schemes for levels of evidence and grades of recommendations, thus giving the reader a good idea of the general framework in which the chapters will be presenting opinions and conclusions. Then follows a section of four chapters covering cranial radiosurgery technology, including frame-based and frameless stereotactic systems and photon and proton delivery systems. These chapters include discussions of system accuracy and dosimetric differences between photons and protons.
The next section has several chapters covering selected topics on benign intracranial lesions. Three of these chapters discuss acoustic neuromas with discussion of single-session and fractionated treatment and open surgery. The available evidence justifying different treatment approaches is examined, with the frequent verdict, throughout the book, that there is no level 1 evidence for particular issues. Two chapters on cavernomas examine the available evidence for and against the use of radiosurgery. Two chapters discuss the radiation dose tolerance of the optic pathways. This may seem like a narrowly focused topic, but it frequently is an important issue, and the two chapters that debate each other are helpful discussions. The last chapter of the section discusses radiosurgery of arteriovenous malformations and the relative merits of surgery, radiosurgery, and embolization, alone or in combinations.
The six chapters of the next section cover management of malignant disease. Two chapters cover the relative merits of surgical resection and radiosurgery for solitary brain metastases, and two chapters debate the use of stereotactic radiosurgery and/or fractionated radiotherapy for multiple brain metastases. The last two chapters review the use of radiosurgery for glioblastoma.
The next section covers functional topics, with two chapters on radiosurgery for trigeminal neuralgia and two chapters on temporal lobe epilepsy. The chapters on trigeminal neuralgia focus on debating where along the trigeminal nerve the radiosurgery target should be placed, rather than how to decide on radiosurgery for this disorder. The discussions do include review of rates of successful treatment, so the critical reader can put radiosurgical treatment in perspective compared to other available treatments such as rhizotomy, microvascular decompression, and pharmacologic management. The first chapter on temporal lobe epilepsy reviews surgical treatment, and the second chapter presents the much more limited experience with radiosurgery.
The next section moves down to the spine and consists of four chapters on radiation tolerance of the spinal cord. The section covers both laboratory and clinical data and is a very useful review, especially given that the volume of experience with spinal radiosurgery is much smaller than the experience with cranial radiosurgery. The combination of spinal radiosurgery and fractionated radiotherapy is an important topic that is covered in this section.
The next section covers differences between single session and multisession spinal radiosurgery and then has two chapters debating the risk of vertebral compression fractures after radiosurgery. The next six chapters are a section on treatment of malignant spine tumors with radiosurgery and/or surgery. Surgical discussions cover a range of approaches, from en bloc resection to only spinal cord decompression. The possible roles of radiosurgery after surgery, instead of surgery, and even before surgery, are discussed. The final section of two chapters describes the relatively limited experience with radiosurgery for benign spinal tumors.
This book is well organized, and discussions are thorough yet succinct. The illustrations are adequate in number and well reproduced. The numbers of references in the different chapters are mostly appropriate, and some chapters have useful tables of references. Overall, this is a very useful book, but a few criticisms can be offered. There is inconsistency in the terminology for levels of evidence and recommendations across the 39 chapters written by multiple authors. A chapter appraising radiosurgical devices and systems used for spinal radiosurgery would have been a useful inclusion. In this age of full disclosure, information on possible conflicts of interest would be appropriate, especially because some of the authors have affiliations with radiosurgical device manufacturers that are not mentioned in the book.
This book is not written specifically for the neuroradiologist, but stereotactic radiosurgery requires a team approach, and the radiologist may be called on to help the neurosurgeon and radiation oncologist with preradiosurgery image assessment or posttreatment follow-up. An appreciation of the complexities and vagaries of the current state of the art may improve the radiologist’s ability to contribute to the team effort.
This book offers very useful reviews of specific topics in radiosurgery. The management of patients with the disorders covered in this book is not always clear-cut. Probably the vast majority of such patients require complex decision-making that takes into account many clinical factors. Evidence from high-quality randomized trials usually is not available to fit the individual’s particular combination of clinical factors. This book acknowledges these difficulties, and it does a good job of assembling the evidence that does exist for particular therapeutic approaches and categorizing the data into currently accepted levels of evidence. The clinician managing such patients must be aware of these various data in order to selectively find the best fit of the different management strategies for the individual patient.
