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Role of radiotherapy in brain tumours

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Different Radiotherapy Modalities in treatment of brain tumors. @D

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Role of radiotherapy in brain tumours

  1. 1. ROLE OF RADIOTHERAPY IN BRAIN TUMORS Dr. Abhilash G JR-3
  2. 2. SEER STATISTICS  Brain tumors account for 1.4% of all cancers  Median age of diagnosis is 58 years.  Incidence is 6.4 per 100,000 men and women per year  The 5-year survival for localized brain and other nervous system cancer is 36.3%.  Brain tumors account for 2.6% of all cancer deaths
  3. 3. INTRODUCTION  Sixty percent of all primary brain tumours are glial tumours, and two-thirds of these are clinically aggressive, high-grade tumours.
  4. 4. COBALT 60 LINAC
  5. 5. INDICATIONS OF RADIOTHERAPY  High Grade Gliomas  Residual Disease  Recurrent Disease  Benign Tumors  Brachytherapy (selected cases)
  6. 6. BENIGN BRAIN TUMORS  Meningioma  Pituitary tumors  Craniopharyngioma  Arteriovenous Malformations  Hemangioblastoma and Hemangiopericytoma  Glomus Jugulare Tumor  Pineocytoma  Chordoma  Vestibular Schwannoma  Ganglioglioma  Central Neurocytoma
  7. 7. TYPES OF RADIOTHERAPY TECHNIQUES
  8. 8.  Conventional 2D approach  3 dimensional conformal radiotherapy (3DCRT)  Stereotactic Radiosurgery and Stereotactic Radiotherapy  Brachytherapy  Proton Beam Therapy
  9. 9. Two Dimensional planning for Brain Tumors
  10. 10. CONTOUR TARGET OUTLINE
  11. 11. PLACE A FIELD
  12. 12. Immobilization • Head Rest • Thermoplastic mask • Base plate
  13. 13. 2-D BEAM ARRANGEMENTS
  14. 14. CONVENTIONAL PLANNING  Disadvantages  Irradiation of large volumes of brain with normal tissue also  Higher toxicity and side effects  Lack of 3D visualization of tumor  2D planning of 3D tumor
  15. 15. 3D CRT
  16. 16. Immobilization Delineation of Target & critical organs Beam Shaping Block , MLC Steps of 3DCRT
  17. 17. TAKING PLANNING CT SLICES IN NEUROONCOLOGY  Different from diagnostic imaging  Use appropriate immobilization device  Image the patient in treatment position
  18. 18. Planning MRI • Position Ideally in treatment position with orfit & base plate. • Transfer images to planning system
  19. 19. Imaging • CT • CT-MR Fusion • PET Scan – limited but emerging role
  20. 20. TARGET DELIENATION
  21. 21. BEAM SHAPING
  22. 22. Multileaf collimators (MLC) Tumor OAR OAR
  23. 23. PLAN EVALUATION
  24. 24. 3-D PLANNING  Advantages  Ideal for all cases  Conformal  Maximum sparing of normal tissue  Lower toxicity
  25. 25. Stereotactic Radiosurgery and Stereotactic Radiotherapy
  26. 26.  “Stereo”: Greek: Solid or 3 dimensional “tact” Latin: To touch: Greek “taxic” an arrangement  Stereotactic: 3 dimensional arrangement to touch  Stereotactic Radiosurgery (SRS): Stereotactically directed conformal radiation in a single fraction  Stereotactic Radiation Therapy (SRT): Stereotactically directed conformal radiation in multiple fractions  Fractionated Stereotactic Radiosurgery (FSR): Stereotactically directed conformal radiation in 2-5 fractions
  27. 27.  Advantages of SRS and SRT over 3DCRT High conformity To treat small lesions not amenable to 3D CRT Higher tumor dose Save larger amount of normal tissue
  28. 28. STEREOTACTIC RADIOSURGERY STEREOTACTIC RADIOTHERAPY Dose per Fraction High Low Number of Fractions 1 Multiple Targeting accuracy <1 mm 3-20 mm
  29. 29. INDICATIONS SRS  Benign and malignant brain tumors  Arteriovenous malformations  Well circumscribed targets < 4 cm diameter SRT  Lesions > 4cm  Lesions located near critical structures
  30. 30. Leksell Frame Brain Lab Non invasive head ring for SRT
  31. 31. GAMMA KNIFE (SRS & SRT)
  32. 32. ADVANTAGES • Over 30 years of clinical use and a large clinical experience • Very high targeting precision • Multiple targets treated during a single treatment session DISADVANTAGES • Use in the brain only • Painful stereotactic head frame • Difficult to treat lesions located in the periphery of the brain • Co sources decay, increasing treatment time and cost to replace after 5 years
  33. 33. LINAC BASED (SRS & SRT)
  34. 34. ADVANTAGES • More commonplace technology in hospitals • No invasive stereotactic frame • Can be used for extracranial tumors also DISADVANTAGES • Painful head frame • Less targeting accuracy and treatment accuracy when treating extracranial tumors
  35. 35. TRUE BEAM
  36. 36. Linear Accelerator Manipulator Image Detectors X-ray Sources IMAGING SYSTEM ROBOTIC DELIVERY SYSTEM TARGETING SOFTWARE Cyber knife
  37. 37. Gamma Knife Cyber Knife Immobilization Invasive Frame Frameless Patient Comfort Moderate Very Good Issue of radioactivity Replacement & Disposal None
  38. 38. BRACHYTHERAPY  bis-Chloronitrosourea (BCNU)-impregnated biodegradable polymer (GLIADEL wafer) may be considered for intraoperative placement if frozen section reveals high grade glioma.  I-125 liquid soaked wafers also used
  39. 39. FUTURISTIC RADIOTHERAPY IN BRAIN TUMORS
  40. 40. PROTON BEAM THERAPY
  41. 41.  Low entrance dose (plateau)  Maximum dose at depth (Bragg peak)  Rapid distal dose fall-off Photons Protons
  42. 42. PROTONS IN CNS TRIALS • Low grade & High grade glioma • Benign brain tumors: – Vestibular Schwannomas/Acoustic Neuromas – Meningioma – Pituitary adenoma – AVM • Skull base tumors: Chordoma/Chondrosarcomas • Pediatric brain tumors: Medulloblastoma, Ependymoma, Pilocytic astrocytoma, Germ cell tumors
  43. 43. EXAMPLE – CASE OF PITUITARY ADENOMA
  44. 44. TWO DIMENSIONAL PLAN
  45. 45. THREE DIMENSIONAL PLAN
  46. 46. CYBER KNIFE PLAN
  47. 47. SUMMARY  Multiple options and techniques available for treating brain tumors.  Need to use the optimum technique  Decision to be based on need of patient and available technique.
  48. 48. THANK YOU

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