Stereotactic Stereotactic Radiosurgery Radiosurgery Gamma knife Gamma knife Cyberknife Cyberknife
Stereotactic RadiosurgeryStereotactic Radiosurgery
Gamma knifeGamma knife
CyberknifeCyberknife
Trends in Melanoma Incidence and Mortality in the
United States
Brain Metastases• 20%–40% of all patients with cancer
develop brain metastases
• Retrospective analysis indicates primary malignancy as:
– Lung cancer (40%)
– Breast carcinoma (17%)
– Malignant melanoma (11%)
• Increasing incidence due to:– Improved treatment of primary malignancy
– Earlier detection of brain metastases
Nussbaum ES et al. Cancer. 2000;78:1781-1788.
Primary and secundary CNS Tumors: Incidence
November 2002
Type of Intracerebral Tumor * Percent Incidence
Secondary carcinoma 40
Gliomas, all types 40
Meningiomas 13
Pituitary adenomas
Neurofibromas
Congenital tumors
Tumors of blood vessels
Others tumors
4
3
* These figures apply to adult populations. In children, about three-quarters of cerebral tumors are gliomas.
Secondary Brain Tumors: Incidence by tumor type
November 2002
Primary Tumor Patients Percentage
Lung
Breast
Melanoma
Colon
Other known primary
Unknown primary
Total
270
82
50
26
72
61
561
48
15
9
5
13
11
100
RESULTS
Changes in Overall CancerMortality (1975-2003), United States
-60
-40
-20
0
20
40
Per
cent
age Melanoma
Prostate Cancer
Breast Cancer
Colorectal Cancer
Cervical Cancer
US SEER Cancer Registry, 2003
Metastatic Brain Tumor• History
– Rapidly progressive onset of symptoms (weeks vs. months) – Most common sources are LUNG, BREAST (in women), RENAL, & G.I. tract
• Diagnostic Imaging Studies– MRI: Tumor at grey-white matter
junction, usually associated with edema– Systemic work-up includes CT scan of
chest and abdomen• Diagnostic Laboratory Studies
– Liver function tests, CBC w/diff• Treatment
– For solitary lesion or less than 4 lesions all < 3 cm. – biopsy if undiagnosed, plus Gamma Knife
– For > 3 cm. tumor, surgery followed by WBRT
– For > 4 lesions, biopsy for diagnosis, plus whole brain radiation therapy.
• Prognosis: 7 – 12 mos.
http://www.neurobc.com/conditions/Brain_metastases.htm
MetastasesMetastases Outnumber all other brain tumors combinedOutnumber all other brain tumors combined >100,000 patients die each year with >100,000 patients die each year with
symptomatic brain metssymptomatic brain mets Common primary tumors:Common primary tumors:
– LungLung– BreastBreast– RenalRenal– MelanomaMelanoma
MetastasesMetastases Medical therapy - steroidsMedical therapy - steroids
– Often dramatic relief of symptomsOften dramatic relief of symptoms Surgical excisionSurgical excision Conventional radiotherapyConventional radiotherapy RadiosurgeryRadiosurgery
Brain metastasesBrain metastases
Tsao et al, Cancer Tr. Rev. 2005Tsao et al, Cancer Tr. Rev. 2005– EBRTEBRT– Stereotactic RTStereotactic RT
60-90% improvement of60-90% improvement of
neurological symptomsneurological symptoms OS benefit in single metastasisOS benefit in single metastasis
Secondary Brain Tumors: Radiotherapy
November 2002
RadiosurgeryRadiosurgery
One time application of high dose, focused One time application of high dose, focused radiationradiation
A variety of machines used to produce the A variety of machines used to produce the radiationradiation– Gamma knifeGamma knife– LINACLINAC– Particle acceleratorParticle accelerator
Stereotactic MRI - Image Fusion
• Volumetric MRI sequence
• Rapid, thin slices, no special equipment
• Avoids errors inherent to direct stereotacticacquisition of MRI data
• Introduces error of image fusion (pixel size)
Dose Planning
• Major goal: Conformality– Maximum dose to target
– Minimum dose to surrounding tissue
• Tools– Arc weighting
– Arc span adjustment
– Multiple isocenters
Whole brain radiation therapy vs. Stereotactic radiosurgery
Role of Stereotactic Radiosurgery in the Management of Brain Metastases
In patients with one brain metastasis without evidence of active cancer elsewhere As a radiation boost following surgical
removal of the metastasis and/or whole brain radiation therapy
In patients with one to three recurrent brain metastases following previous whole brain radiation therapy
What is Stereotactic What is Stereotactic Radiosurgery?Radiosurgery?
It is a procedure that has to do with It is a procedure that has to do with delivering high doses of radiation to delivering high doses of radiation to specific targets in the body in order to specific targets in the body in order to destroy tumors, lesions and other destroy tumors, lesions and other cancerous tissue. It uses cross-fired cancerous tissue. It uses cross-fired beams of radiation delivered from multiple beams of radiation delivered from multiple points outside the body. Radiosurgery has points outside the body. Radiosurgery has been around since the early Sixties.been around since the early Sixties.
Computerized Image of Computerized Image of RadiosurgeryRadiosurgery
What is Gamma Knife?What is Gamma Knife?
Side view of the Gamma KnifeSide view of the Gamma Knife
Patient Couch HelmetHelmet in treatment position
Shielding Radiation source
Collimator up closeCollimator up close
Helmet (collimators)
Stereotactic headframe
What is Cyberknife?What is Cyberknife?
Detailed view of CyberknifeDetailed view of Cyberknife
Linear accelerator
Robotic Arm
Radiation Exit point
Patient couch
CRT linear acceleratorCRT linear accelerator
A – Cathode
B – Conductive
coating
C – Anode
D – Phosphor
Coated screen
E – Electron Beams
F – Shadow mask
**A particle accelerator works basically the same way.
Brain Lab Novalis®
- 3 – 5.5 mm micro-multileaf collimator to conform to the shape of the target
- Dynamic conformal arc therapy
www.albertaradiosurgery.ca
Trials Ongoing/Planned
• Radiosurgery +/- WBXRT
• Doses of PCI in SCLC
• +/- PCI in NSCLC
• WBXRT +/- radiation sensitizer
• Avastin for GBM
• Neurogenic agents for XRT injury
Radiation Protection in Radiotherapy
Stereotactic proceduresStereotactic procedures
Target usually brain lesionsTarget usually brain lesions External head frame used to ensure External head frame used to ensure
accurate patient accurate patient positioningpositioning
Invasive orInvasive or Re-locatableRe-locatable
Radiation Protection in Radiotherapy
Image registrationImage registration Variety of systemsVariety of systems Many frame Many frame
attachments to attachments to allow for different allow for different diagnostic diagnostic modalities (MRI, modalities (MRI, CT, angiography)CT, angiography)
Radiation Protection in Radiotherapy
Image registrationImage registration
CT scan MRI
Leksell fiducial markers on both
Radiation Protection in Radiotherapy
Stereotactic proceduresStereotactic procedures
Spatial accuracy around 1mmSpatial accuracy around 1mm High dose single fraction (High dose single fraction (e.g.e.g. for for
arterio-venous malformations) = arterio-venous malformations) = stereotactic radiosurgery using an stereotactic radiosurgery using an invasively mounted head frameinvasively mounted head frame
Multiple fractions for tumour Multiple fractions for tumour treatment = stereotactic treatment = stereotactic radiotherapy using a re-locatable radiotherapy using a re-locatable head immobilisationhead immobilisation
Both systems MedTec
Stephan Eisenschenk, MD
UF LINAC Stereotactic Radiosurgery- Gantry
Radiation treatmentRadiation treatment
► Conventional radiation: Conventional radiation:
effective in< 20% of caseseffective in< 20% of cases► SRS: for small (Nidus<3cm) & deep SRS: for small (Nidus<3cm) & deep
AVMsAVMs► Radiation-induced endothelial cell Radiation-induced endothelial cell
proliferationproliferation→→Obliteration, thrombosisObliteration, thrombosis► Gamma knife/ LinacGamma knife/ Linac
► Non-invasive, gradual reduction of flowNon-invasive, gradual reduction of flow► Takes 1-3 yrs to work, limited to small Takes 1-3 yrs to work, limited to small
lesionlesion
Radiation Protection in Radiotherapy
GammaknifeGammaknife
Used for stereotactic brain irradiationsUsed for stereotactic brain irradiations 201 sources of Co-60 around a patients 201 sources of Co-60 around a patients
head - only sources which shall head - only sources which shall contribute to the irradiation are contribute to the irradiation are ‘unplugged’‘unplugged’
alignment crucialalignment crucial
Radiation Protection in Radiotherapy
Gamma knife head applicatorGamma knife head applicator
Radiation Protection in Radiotherapy
Patient in gamma knife collimator head Patient in gamma knife collimator head (from Ertl (from Ertl et al.et al. Phys. Med. Biol. 42 (1997) 2137) Phys. Med. Biol. 42 (1997) 2137)
Secondary Brain Tumors: Surgery
Galicich JH et al., Met. Brain tumors,In Wilkins: Neurosurgery, 597-61, 1985. November 2002
Secondary Brain Tumors: Radiotherapy
November 2002
030
x030 s
12 2.5 152
Secondary Brain Tumors: Radiotherapy
November 2002
Vincent Breton, cours ISIMA, 14/12/04
La radiothérapie est couramment utilisée pour traiter le cancer
2°) Treatment planning
Calculation ofdeposit dose on the tumor
(~1mn):A treatment plan is
developed using the images
1°) Obtain scanner slices images
The head is imaged using a MRI and/or CT scanner
3°) Radiotherapy treatment
Irradiation of the brain tumor with a
linear accelerator
Linear acceleratorLinear accelerator
Brain tumors: managementBrain tumors: management
seizures
symptomatic treatment: anticonvulsants
prophylactic treatment: controversial
- two randomized prospective studies (>170 pts with both primary and metastatic brain tumors) showed no significant benefit with prophylactic treatment
- possible exceptions: melanoma brain mets, pts w/ both brain mets and leptomeningeal mets (both groups 50-60% risk of seizures)
RTOG 0023: Results
Cardinale, Red J, 2006
FSRT MIGHT BENEFIT GROSS-TOTALLY RESECTED GBM
Although overall survivalwas not improved, there was a trend toward improvedsurvival with FSRT forpatients with total resection
Gamma Knife Radiosurgery• Indications
– Tumors (Benign & Malignant, Primary & Metastatic)– Arteriovenous malformations– Trigeminal neuralgia– Functional neurosurgery, to create lesions (controversial)
• Success Rate– Comparable success rate for tumors vs.
surgery/conventional radiation, with fewer side effects/morbidity/mortality
• Limitations– Tumors must be smaller (<3 cm.), and once a lesion is
made, it cannot be undone (irreversible)
• Side Effects/Complications– Rare, can include edema post-procedure
Gamma Knife Radiosurgery• The Principle:
– 201 cobalt-60 generated particles focus on one region, to deliver maximal energy to that region and minimal amount to surrounding brain tissue. Effects occur over weeks to months, although edema may be seen earlier. Patients are observed overnight, and then discharged.
http://www.sh.lsuhsc.edu/neurosurgery/gammaknife/gamma-knife/
Specialized Devices for SBRTSpecialized Devices for SBRT
Novalis Cyberknife Accelerator-based IGRT
(Trilogy, Synergy)
WFUBMC SBRTWFUBMC SBRT3-D Imaging Device3-D Imaging Device
Phillips PQ 5000 CT simulator
Single slice acquisition External lasers for
isocenter placement AcQSim software
WFUBMC SBRTWFUBMC SBRT
Varian 2100 SCX accelerator
6MV photon beam 120 leaf MLC Portal Vision
Metastatic Brain Tumor• History
– Rapidly progressive onset of symptoms (weeks vs. months) – Most common sources are LUNG, BREAST (in women), RENAL, & G.I. tract
• Diagnostic Imaging Studies– MRI: Tumor at grey-white matter
junction, usually associated with edema– Systemic work-up includes CT scan of
chest and abdomen• Diagnostic Laboratory Studies
– Liver function tests, CBC w/diff• Treatment
– For solitary lesion or less than 4 lesions all < 3 cm. – biopsy if undiagnosed, plus Gamma Knife
– For > 3 cm. tumor, surgery followed by WBRT
– For > 4 lesions, biopsy for diagnosis, plus whole brain radiation therapy.
• Prognosis: 7 – 12 mos.
http://www.neurobc.com/conditions/Brain_metastases.htm
Gamma Knife Radiosurgery• Indications
– Tumors (Benign & Malignant, Primary & Metastatic)– Arteriovenous malformations– Trigeminal neuralgia– Functional neurosurgery, to create lesions (controversial)
• Success Rate– Comparable success rate for tumors vs.
surgery/conventional radiation, with fewer side effects/morbidity/mortality
• Limitations– Tumors must be smaller (<3 cm.), and once a lesion is
made, it cannot be undone (irreversible)
• Side Effects/Complications– Rare, can include edema post-procedure
Gamma Knife Radiosurgery• The Principle:
– 201 cobalt-60 generated particles focus on one region, to deliver maximal energy to that region and minimal amount to surrounding brain tissue. Effects occur over weeks to months, although edema may be seen earlier. Patients are observed overnight, and then discharged.
http://www.sh.lsuhsc.edu/neurosurgery/gammaknife/gamma-knife/
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