Stereotactic Radiosurgery

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Stereotactic Radiosurgery

  1. 1. Stereotactic Radiosurgery Gamma knife Cyberknife
  2. 2. Trends in Melanoma Incidence and Mortality in the United States
  3. 3. Brain Metastases <ul><li>20%–40% of all patients with cancer develop brain metastases </li></ul><ul><li>Retrospective analysis indicates primary malignancy as: </li></ul><ul><ul><li>Lung cancer (40%) </li></ul></ul><ul><ul><li>Breast carcinoma (17%) </li></ul></ul><ul><ul><li>Malignant melanoma (11%) </li></ul></ul><ul><li>Increasing incidence due to: </li></ul><ul><ul><li>Improved treatment of primary malignancy </li></ul></ul><ul><ul><li>Earlier detection of brain metastases </li></ul></ul>Nussbaum ES et al. Cancer . 2000;78:1781-1788.
  4. 4. Primary and secundary CNS Tumors: Incidence November 2002 * These figures apply to adult populations. In children, about three-quarters of cerebral tumors are gliomas. 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
  5. 5. 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
  6. 6. RESULTS
  7. 7. Changes in Overall Cancer Mortality (1975-2003), United States US SEER Cancer Registry, 2003
  8. 8. Metastatic Brain Tumor <ul><li>History </li></ul><ul><ul><li>Rapidly progressive onset of symptoms (weeks vs. months) – Most common sources are LUNG, BREAST (in women), RENAL, & G.I. tract </li></ul></ul><ul><li>Diagnostic Imaging Studies </li></ul><ul><ul><li>MRI: Tumor at grey-white matter junction, usually associated with edema </li></ul></ul><ul><ul><li>Systemic work-up includes CT scan of chest and abdomen </li></ul></ul><ul><li>Diagnostic Laboratory Studies </li></ul><ul><ul><li>Liver function tests, CBC w/diff </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>For solitary lesion or less than 4 lesions all < 3 cm. – biopsy if undiagnosed, plus Gamma Knife </li></ul></ul><ul><ul><li>For > 3 cm. tumor, surgery followed by WBRT </li></ul></ul><ul><ul><li>For > 4 lesions, biopsy for diagnosis, plus whole brain radiation therapy. </li></ul></ul><ul><li>Prognosis: 7 – 12 mos. </li></ul>http://www.neurobc.com/conditions/Brain_metastases.htm
  9. 9. Metastases <ul><li>Outnumber all other brain tumors combined </li></ul><ul><li>>100,000 patients die each year with symptomatic brain mets </li></ul><ul><li>Common primary tumors: </li></ul><ul><ul><li>Lung </li></ul></ul><ul><ul><li>Breast </li></ul></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><li>Melanoma </li></ul></ul>
  10. 10. Metastases <ul><li>Medical therapy - steroids </li></ul><ul><ul><li>Often dramatic relief of symptoms </li></ul></ul><ul><li>Surgical excision </li></ul><ul><li>Conventional radiotherapy </li></ul><ul><li>Radiosurgery </li></ul>
  11. 11. Brain metastases <ul><li>Tsao et al, Cancer Tr. Rev. 2005 </li></ul><ul><ul><li>EBRT </li></ul></ul><ul><ul><li>Stereotactic RT </li></ul></ul><ul><li>60-90% improvement of </li></ul><ul><li>neurological symptoms </li></ul><ul><li>OS benefit in single metastasis </li></ul>
  12. 15. Secondary Brain Tumors: Radiotherapy November 2002
  13. 16. Radiosurgery <ul><li>One time application of high dose, focused radiation </li></ul><ul><li>A variety of machines used to produce the radiation </li></ul><ul><ul><li>Gamma knife </li></ul></ul><ul><ul><li>LINAC </li></ul></ul><ul><ul><li>Particle accelerator </li></ul></ul>
  14. 17. Treatment Paradigm
  15. 21. Whole brain radiation therapy vs. Stereotactic radiosurgery
  16. 22. Role of Stereotactic Radiosurgery in the Management of Brain Metastases <ul><li>In patients with one brain metastasis without evidence of active cancer elsewhere </li></ul><ul><ul><li>As a radiation boost following surgical removal of the metastasis and/or whole brain radiation therapy </li></ul></ul><ul><li>In patients with one to three recurrent brain metastases following previous whole brain radiation therapy </li></ul>
  17. 23. What is Stereotactic Radiosurgery? <ul><li>It is a procedure that has to do with delivering high doses of radiation to specific targets in the body in order to destroy tumors, lesions and other cancerous tissue. It uses cross-fired beams of radiation delivered from multiple points outside the body. Radiosurgery has been around since the early Sixties. </li></ul>
  18. 24. Computerized Image of Radiosurgery
  19. 25. What is Gamma Knife?
  20. 26. Side view of the Gamma Knife Patient Couch Helmet Helmet in treatment position Shielding Radiation source
  21. 27. Collimator up close Helmet (collimators) Stereotactic headframe
  22. 28. What is Cyberknife?
  23. 29. Detailed view of Cyberknife Linear accelerator Robotic Arm Radiation Exit point Patient couch
  24. 30. CRT 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.
  25. 31. Brain Lab Novalis ® - 3 – 5.5 mm micro-multileaf collimator to conform to the shape of the target - Dynamic conformal arc therapy
  26. 32. www.albertaradiosurgery.ca
  27. 33. Trials Ongoing/Planned <ul><li>Radiosurgery +/- WBXRT </li></ul><ul><li>Doses of PCI in SCLC </li></ul><ul><li>+/- PCI in NSCLC </li></ul><ul><li>WBXRT +/- radiation sensitizer </li></ul><ul><li>Avastin for GBM </li></ul><ul><li>Neurogenic agents for XRT injury </li></ul>
  28. 34. Stereotactic procedures <ul><li>Target usually brain lesions </li></ul><ul><li>External head frame used to ensure accurate patient positioning </li></ul><ul><li>Invasive or </li></ul><ul><li>Re-locatable </li></ul>
  29. 35. Image registration <ul><li>Variety of systems </li></ul><ul><li>Many frame attachments to allow for different diagnostic modalities (MRI, CT, angiography) </li></ul>
  30. 36. Image registration CT scan MRI Leksell fiducial markers on both
  31. 37. Stereotactic procedures <ul><li>Spatial accuracy around 1mm </li></ul><ul><li>High dose single fraction ( e.g. for arterio-venous malformations) = stereotactic radiosurgery using an invasively mounted head frame </li></ul><ul><li>Multiple fractions for tumour treatment = stereotactic radiotherapy using a re-locatable head immobilisation </li></ul>Both systems MedTec
  32. 38. UF LINAC Stereotactic Radiosurgery- Gantry
  33. 39. Radiation treatment <ul><li>Conventional radiation: </li></ul><ul><li>effective in< 20% of cases </li></ul><ul><li>SRS: for small (Nidus<3cm) & deep AVMs </li></ul><ul><li>Radiation-induced endothelial cell proliferation -> Obliteration, thrombosis </li></ul><ul><li>Gamma knife/ Linac </li></ul><ul><li>Non-invasive, gradual reduction of flow </li></ul><ul><li>Takes 1-3 yrs to work, limited to small lesion </li></ul>
  34. 40. Gammaknife <ul><li>Used for stereotactic brain irradiations </li></ul><ul><li>201 sources of Co-60 around a patients head - only sources which shall contribute to the irradiation are ‘unplugged’ </li></ul><ul><li>alignment crucial </li></ul>
  35. 41. Gamma knife head applicator
  36. 42. Patient in gamma knife collimator head (from Ertl et al. Phys. Med. Biol. 42 (1997) 2137)
  37. 43. Secondary Brain Tumors: Surgery Galicich JH et al ., Met. Brain tumors,In Wilkins: Neurosurgery, 597-61, 1985. November 2002
  38. 44. Secondary Brain Tumors: Radiotherapy November 2002 0 30 x 0 30 s 1 5 2 12 2.5
  39. 45. Secondary Brain Tumors: Radiotherapy November 2002
  40. 48. La radiothérapie est couramment utilisée pour traiter le cancer 2°) Treatment planning Calculation of deposit 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
  41. 50. Linear accelerator
  42. 52. Brain tumors: management <ul><li>seizures </li></ul><ul><li>symptomatic treatment: anticonvulsants </li></ul><ul><li>prophylactic treatment: controversial </li></ul><ul><li>- two randomized prospective studies (>170 pts with both primary and metastatic brain tumors) showed no significant benefit with prophylactic treatment </li></ul><ul><li>- possible exceptions: melanoma brain mets, pts w/ both brain mets and leptomeningeal mets (both groups 50-60% risk of seizures) </li></ul>
  43. 54. RTOG 0023: Results Cardinale, Red J, 2006 FSRT MIGHT BENEFIT GROSS-TOTALLY RESECTED GBM Although overall survival was not improved, there was a trend toward improved survival with FSRT for patients with total resection
  44. 55. Gamma Knife Radiosurgery <ul><li>Indications </li></ul><ul><ul><li>Tumors (Benign & Malignant, Primary & Metastatic) </li></ul></ul><ul><ul><li>Arteriovenous malformations </li></ul></ul><ul><ul><li>Trigeminal neuralgia </li></ul></ul><ul><ul><li>Functional neurosurgery, to create lesions (controversial) </li></ul></ul><ul><li>Success Rate </li></ul><ul><ul><li>Comparable success rate for tumors vs. surgery/conventional radiation, with fewer side effects/morbidity/mortality </li></ul></ul><ul><li>Limitations </li></ul><ul><ul><li>Tumors must be smaller (<3 cm.), and once a lesion is made, it cannot be undone (irreversible) </li></ul></ul><ul><li>Side Effects/Complications </li></ul><ul><ul><li>Rare, can include edema post-procedure </li></ul></ul>
  45. 56. Gamma Knife Radiosurgery <ul><li>The Principle: </li></ul><ul><ul><li>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. </li></ul></ul>http://www.sh.lsuhsc.edu/neurosurgery/gammaknife/gamma-knife/
  46. 57. Specialized Devices for SBRT <ul><li>Novalis </li></ul><ul><li>Cyberknife </li></ul><ul><li>Accelerator-based IGRT (Trilogy, Synergy) </li></ul>
  47. 58. WFUBMC SBRT 3-D Imaging Device <ul><li>Phillips PQ 5000 CT simulator </li></ul><ul><li>Single slice acquisition </li></ul><ul><li>External lasers for isocenter placement </li></ul><ul><li>AcQSim software </li></ul>
  48. 59. WFUBMC SBRT <ul><li>Varian 2100 SCX accelerator </li></ul><ul><li>6MV photon beam </li></ul><ul><li>120 leaf MLC </li></ul><ul><li>Portal Vision </li></ul>
  49. 60. Metastatic Brain Tumor <ul><li>History </li></ul><ul><ul><li>Rapidly progressive onset of symptoms (weeks vs. months) – Most common sources are LUNG, BREAST (in women), RENAL, & G.I. tract </li></ul></ul><ul><li>Diagnostic Imaging Studies </li></ul><ul><ul><li>MRI: Tumor at grey-white matter junction, usually associated with edema </li></ul></ul><ul><ul><li>Systemic work-up includes CT scan of chest and abdomen </li></ul></ul><ul><li>Diagnostic Laboratory Studies </li></ul><ul><ul><li>Liver function tests, CBC w/diff </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>For solitary lesion or less than 4 lesions all < 3 cm. – biopsy if undiagnosed, plus Gamma Knife </li></ul></ul><ul><ul><li>For > 3 cm. tumor, surgery followed by WBRT </li></ul></ul><ul><ul><li>For > 4 lesions, biopsy for diagnosis, plus whole brain radiation therapy. </li></ul></ul><ul><li>Prognosis: 7 – 12 mos. </li></ul>http://www.neurobc.com/conditions/Brain_metastases.htm
  50. 61. Gamma Knife Radiosurgery <ul><li>Indications </li></ul><ul><ul><li>Tumors (Benign & Malignant, Primary & Metastatic) </li></ul></ul><ul><ul><li>Arteriovenous malformations </li></ul></ul><ul><ul><li>Trigeminal neuralgia </li></ul></ul><ul><ul><li>Functional neurosurgery, to create lesions (controversial) </li></ul></ul><ul><li>Success Rate </li></ul><ul><ul><li>Comparable success rate for tumors vs. surgery/conventional radiation, with fewer side effects/morbidity/mortality </li></ul></ul><ul><li>Limitations </li></ul><ul><ul><li>Tumors must be smaller (<3 cm.), and once a lesion is made, it cannot be undone (irreversible) </li></ul></ul><ul><li>Side Effects/Complications </li></ul><ul><ul><li>Rare, can include edema post-procedure </li></ul></ul>
  51. 62. Gamma Knife Radiosurgery <ul><li>The Principle: </li></ul><ul><ul><li>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. </li></ul></ul>http://www.sh.lsuhsc.edu/neurosurgery/gammaknife/gamma-knife/
  52. 63. Thanks for Your Attention & Have a Good Day!!!

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