Multisession Cyberknife radiosurgery for the treatment of advanced-stage intracranial extended Juvenile nasopharyngeal angiofibrom

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Background: A case of a large advanced stage juvenile nasopharyngeal angiofibroma (JNA) treated with combined temporally and volume fractionated CyberKnife radiosurgery (CKRS) is presented. The optimal modality for treating advanced JNA continues to be controversial because of the complications associated with surgical resection and the potential delayed morbidity of radiotherapy (RT) in a pediatric age group. Clinical Presentation: CKRS treatment was delivered with a volume fractionation method. First, for the lower two-thirds of the tumor occupying the nasal cavity, pterygopalatine fossa, maxillary sinus, and ethmoid sinus, CKRS was administered in five fractionated treatments of 7.0 Gy to the 71.7% prescription isodose. This lower part of the tumor volume was 56.4cm 3 . Next, for the upper one-third of the tumor occupying the sphenoid sinus, infratemporal fossa and intracranial left cavernous sinus, CKRS was administered in five fractionated treatments of 6.2 Gy to the 72.1% prescription isodose. This upper part of the tumor volume was 25.2 cm 3 . Post-treatment, a gradual reduction in the whole tumor volume was observed continuously over the course of follow-up, and the patency of the internal carotid artery was restored. Radiation-related complications were limited to nasal mucosal crust formation. Conclusion: A case of a large advanced stage JNA treated with CKRS using combined temporal and volume fractionated CKRS is presented. Follow-up revealed reasonable continuous reduction in tumor volume and the normal patency of the internal carotid artery without any radiation-related complication except for nasal mucosal crust formation. Longer follow-up is needed to evaluate late morbidity and long-term disease control.