SRS/SBRT experience at Maharaja Gandhi Cancer Hospital for the first 50 cases: - SRS/SBRT uses precisely focused radiation beams to treat tumors with high doses in a single or few fractions while avoiding damage to surrounding tissue. - Their experience includes cranial and extracranial tumors treated with SRS and SBRT such as brain metastases, meningiomas, pituitary tumors, and tumors in the liver, spine, and lymph nodes. - Outcomes have been good with response seen on follow up imaging for various tumors including metabolic/structural resolution of treated lesions. - The hospital is well equipped for SRS/SBRT with a dedicated machine, immobil

1. SRS/SBRT
MAHATMA GANDHI CANCER HOSPITAL AND
RESEARCH INSTITUTE, VISAKHAPATNAM
OUR EXPERINCE OF FIRST 50 CASES
DR KANHU CHARAN PATRO
1

2. WHAT IS SRS/SBRT?
• Stereotactic radiosurgery (SRS) uses many precisely
focused radiation beams to treat tumors and other
problems in the brain, neck, lungs, liver, spine and
other parts of the body.
• It is not surgery in the traditional sense because
there's no incision.
• SRS is for cranial
• SBRT for extracranial
2

3. THE DIFFERNCE CONVENTIONAL VS STEREOTAXY
E. H. Balagamwala/Technology in Cancer Research and Treatment/2012 3

4. The duo
• High dose
• Strict immobilization
4

5. 5

6. • Massive vascular damage causes indirect tumor death-it is endothelial cell
inflammation and apoptosis via the sphingomyelin pathway causing
subsequent microvascular dysfunction that are the triggers for tumor cell
death
• 4 r of radiobiology in different manner
• No Repair after ablative dose
• Treatment is for short period no chance of Repopulation
• No Reoxygenation of hypoxic cells due to massive vascular destruction by
SRS/SBRT
• Redistribution dose not happen as more cells die because of massive cell
death
• Massive immunogenic reaction
• Abscopal effect
RADIOBIOLOGY BEHIND STEROTAXY
6

7. The spectrum
• SRS
– Smaller lesion usually less than 3 cm.
– Single fraction
• FRACTIONATED SRS
– Relatively larger tumor
– 1 to 5 fractions
• SRT
– Larger tumor usually more than 3 cm
– Close to vital structures
7

8. The spectrum
• Malignant
– Metastasis
– Recurrent Gliomas
• Benign
– Arteriovenous Malformation
– Vestibular Schwannoma
– Pituitary
– Cavernomas
• Functional
– Trigeminal Neuralgia
– Tremor
– Epileptic Focus
8

9. The wide spectrum
Cranial
– Metastasis
• De novo
• After WBRT
– Arteriovenous malformation
– Vestibular schwannoma
– Reirradiation glioma
– Glomus jugularae
– Hamartoma
– Cavernoma
– Meningioma
– Trigeminal neuralgia
– Tremor
– Epilepsy
Extracranial
– Bone metastasis
– Prostate
– Lung primary/ metastasis
– Pancreas
– Adrenal metastasis
– Liver metastasis/HCC
– Spine metastasis
– Nodal recurrence
– Head and neck reirradiation
9

10. • Malignant cases -- Weeks to months
• Benign cases -- Months to years
• Functional cases -- Days
• Different criteria for different tumors e.g
– RECIST
– PERCIST
– RANO
– And many more
RESPONSE EVALUATION
10

11. WHAT are the requirements?
• Micro MLC/cone
• Planning system
• Imaging
• Immobilization
• Respiratory Motion management system
• QA accessories
• CBCT
• Protocols
11

12. WHAT we have – machine
12

13. WHAT we have – micro MLC
13

14. WHAT we have – CONE
14

15. WHAT we have – immobilization
15
FRAXION

16. WHAT we have – immobilization
16

17. WHAT we have – motion management
17
SYMMETRY

18. WHAT we have – motion management
18
Abdominal compression

19. We have – ABC
19
ABC- ACTIVE BREATH COORDINATOR

20. • CT
• PETCT
– DOTA
– PSMA
– FDG
• MRI
IMAGING WE HAVE
20

21. WHAT we have – planning system
21

22. WHAT we have? – Ray Search planning system
22
FIRST IN INDIA-PHOTON

23. WHAT we have – verification system
23

24. • CBCT CORRECTIONS
Set-up verification-CBCT
24

25. WHAT we have – Hexapod
25

26. • HEXAPOD CORRECTIONS
Set-up verification- HEXAPOD
26

27. • MECHANICAL ISOCENTER CHECK
– WINSTON LUTZ TEST
• POINT DOSE VERIFICATION
• TOLERANCE-1MM
Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015
QA part
27

28. 28
What we follow?

29. 29

30. 30

31. 31

32. 32
Approval

33. Started on July 2019
33

34. Cases completed till today
34

35. Cases completed till today
35
 Brain metastasis 16
 Brain metastasis after whole brain RT 8
 Brain metastasis cavity SRS 3
 Vestibular schwannoma 5
 Arteriovenous malformation 1
 Meningioma 5
 Pituitary 1
 Spine metastasis 3
 Bone metastasis 1
 Cranial cavernoma 2
 Liver metastasis 3
 Hepatocellular carcinoma 1
 Lung cancer 1
 Nodal recurrence 1
TOTAL 51

36. OUR STEREOTAXY EXPERIENCE
36

37. BRAIN METASTASIS SRS
CASE-1
37

38. • NAME
• UMR
• PRESENTATION • 70 YEAR FEMALE
• TRIPLE NEGATIVE BREAST CANCER
• POST MRM
• POST RT/CHEMO
• 6 MONTH FOLLOW UP
• PRESENTED WITH HEADACHE AND GIDDINESS
• MRI • 2.2cm x2.2 cm LESION
• LT.OCCIPITAL LOBE
• RING ENHANCEMENT
• NO MASS EFFECT
• NO MID LINE SHIFT
• MINIMAL EDEMA
• PET CT • MULTIPLE LUNG NODULES
• BRAIN LESION INCREASED Uptake
• SRS • SRS
• 18Gy/1#
Case details
38

39. Pre SRS
39

40. SRS PALN
40

41. POST SRS 3 MONTHS
41

42. BRAIN METASTASIS CAVITY SRS
CASE-2
42

43. • NAME
• UMR
• PRESENTATION • SEIZURES, UNCONSCIOUS
• MRI • 3.2X3.2CM, LEFT OCCIPITAL LOBE,EDEMA,CONTRAST
ENHANCEMNET
• SURGERY • TOTAL EXCISON
• BIOPSY • METASTATIC PAPILLARY ADENOCARCINOMA
• PET CT • RT LUNG LESION
• MULTIPLE NODULE BOTH LUNG
• LESION IN BRAIN
• MEDIASTINAL NODE
• SRS • CAVITY SRS 30Gy/5#
• IHC • EGFR+VE
• EXON21 MUTATION
• ALK NEG
• TTF1 +VE
• CHEMO • PEMETRXED AND CARBOPLATIN
• OMERTINIB 80MG
Case details
43

44. Pre op
44

45. Post op 1 month
45

46. 46
FRACTIONATED SRS
• ADJACENT DURA and
SURGICAL TRACT
• BONE FLAP INNER PART
• CAVITY PROPER
• DURAL SINUS
• ENHANCING COMPONENT

47. Post RT 3 months
47

48. VESTIBULAR SCHWANNOMA SRS
CASE-3
48

49. • NAME
• UMR
• PRESENTATION • 59 year male
• Diagnosed case of vestibular schwannoma
• Right side
• P/w Slight decreasing in hearing loss-4 - 5 months
• No facial numbness
• MRI • Intracanalicular and extra canalicular component
• Touching brainstem
• No cystic component
• Minimal enhancing
• Impending 5th nerve
• SRS • SRS
• 25Gy/5#
Case details
49

50. LT. Fifth
nerve
RT. Fifth
nerve
50

51. Beam arrangement
51

52. 6MONTH FOLLW UP
52

53. NODAL RECURRENCE SBRT
CASE- 4
53

54. • NAME
• UMR
• Diagnosis • Cancer cervix with common iliac node
• RADIATION • EBRT –VMAT SIB 50Gy/25# -56Gy/28#
• REGULAR FOLLOW UP • Post RT 3month - CR
• Presented with • DVT and left leg pain
• PET • Nodal recurrence same area
• Planned SBRT • 30Gy/5#
• PET POST SBRT 3M • Decreased SUV value
• Now • Follow/up
Case details
54

55. 55
At diagnosis

56. 56
At 3 month post RT

57. 57
At 1 year post RT

58. 58
Planned SBRT

59. 59
At 3 month post SBRT

60. 60
At 6 month post SBRT

61. LIVER METASTASIS SBRT
CASE-5
61

62. • NAME
• UMR
• PRESENTATION • 50 YEAR
• MALE
• COLON CANCER
• FOUND LIVER MET DURING SURGERY
• 2 LESIONS
• PET • 2 LESIONS
• SEGMENT VIII SUV-13
• SEGMENT V
• FNAC • ADENO
• CP SCORE • A
• SBRT • 40Gy/5# WITH DIBH
Case details
62

63. 63

64. 64

65. SPINE METASTASIS SBRT
CASE-6
65

66. • NAME
• UMR
• Diagnosis • Ca Lung left lower lobe with D11 bone metastasis
• Presented with • Cough with expectoration, Pain over left chest wall,
Upper backache
• PET • Soft tissue enhancing lesion 5.2cm in LLL abutting pleura
s/o primary
• Hypermetabolic lesion in D11 vertebra (SUV max- 8) –
s/o metastasis
• Planned SBRT • 25Gy/5#
• PET POST SBRT 3M • Complete metabolic resolution of the D11 vertebral
lesion s/o favourable response to treatment
• COURTESY • DR VKR
Case details
66

67. 67
Spine metastasis

68. 68
Target delineation

69. 69
Planned SBRT

70. 70
3 month follow up scan

71. HEPATOCELLULAR CARCINOMA SBRT
CASE-7
71

72. • NAME
• UMR
• Diagnosis • Hepatocellular carcinoma
• Presented with • Diagnosed during screening
• PET • Small lesion in segment 7
• Planned SBRT • 45Gy/3#
• PET POST SBRT 3M • Complete resolution
• Now • f/up
• COURTESY • DR VKR
Case details
72

73. CT/MRI
73

74. TARGET
74

75. SBRT PLAN
75

76. 3 month follow up
76

77. BONE METASTASIS SBRT
CASE-8
77

78. • NAME
• UMR
• Diagnosis • Metastatic Carcinoma Breast
• Presented with • Pain over left hip
• PET • Increased tracer uptake is seen in left acetabulum along
the posterior margin and the left ischium showing
sclerotic changes (SUV max - 6)
• Planned SBRT • 33Gy/3#
• PET POST SBRT 3M • No definite focal hypermetabolic or abnormally
enhancing lesion
• Increased sclerotic changes in the lesions noted in left
acetabulum, ischium and inferior pubic ramus – s/o
complete metabolic response
• COURTESY • DR PSB
Case details
78

79. 79
Isolated bone mets

80. TARGET
80

81. 81
Planned SBRT

82. 82
At 6 month follow up

83. AVM SRS
CASE-9
83

84. • NAME
• UMR
• PRESENTATION • 23 year female
• ECOG-1
• Sudden onset headache
• Weakness of left upper and lower limb
• Evaluated outside
• Images not available
• MRI • Location-Right high posterior parietal vascular malformation
• Malformation size 3.4cm x 2.9cm x3.4cm
• Nidus size 1.6cm x 1.4cm
• Arterial supply- Pericollasal and collasomarginal branches of right
anterior cerebral artery
• Venous drainage- cortical veins along the right posterior parietal
region
• Hemoglobin degradation products with gliosis and
enchephalomalacia.
• SBRT • 18Gy/1#
84

85. MR ANGIO after 3 months
85

86. T1/T2- after 3 months
86

87. DSA THE GOLD STANDARD
87

88. CT ANGIO
88

89. The beam arrangement
89

90. 6 month follow up
90

91. MENINGIOMA SRS
CASE-10
91

92. • NAME
• UMR
• PRESENTATION • HEADACHE LEFT SIDED, LEFT EYE PAIN
• MRI • 2.2×1.9×2.3CM, INTENSELY ENHANCING EXTRA AXIAL LESION T2W
HYPOINTENSE & ISOINTENSE T1W ON LEFT SIDE POSTERIOR TO
CAVERNOUS SINUS AND INDENTING PONS. LATERALLY ENCASING
LEFT TRIGE
• SURGERY • NEAR TOTAL EXCISON
• HPE • S/O TRANSITIONAL MENINGIOMA (WHO GRADE I)
• DOTA PET CT • 1.2×0.6 CM LESION NOTED IN THE LEFT PETROCLIVAL REGION
,POSTERIOR TO THE CAVERNOUS SINUS WITH SUV MAX - 7
• PLAN • SRS – 15Gy IN 1#
Case details
92

93. 93
Petroclival meningioma

94. 94
Dota scan

95. 95
SRS plan

96. 6 month follow up
96

97. Pituitary
CASE-11
97

98. • NAME
• UMR
• PRESENTATION • Vomiting, Head reeling sensation, Involuntary movements of all
limbs
• MRI 1. 2.3 × 1.6 × 1.6 cm, Dumbbell shaped lesion in sellar region
2. Extending into Suprasellar location
3. Pituitary gland not separated from lesion
4. Optic chiasm – compressed & superiorly displaced
5. Doubtful B/L Parasellar extension (R>L) with encasement of
cavernous segment B/L ICA (R>L)
• SURGERY • Endoscopic Trans sphenoid Excision and Near total excision
• BIOPSY • F/S/O Pituitary Macro adenoma
• SRS • FSRT – 25Gy / 5#
• IHC • Synaptophysin +VE ,
• Chromogranin +VE
Case details
98

99. Target
99

100. SRS PLAN
100

101. 6 month follw up- awaited
101

102. GLOMUS JUGULARAE
CASE-12
102

103. • NAME
• UMR
• PRESENTATION • Headache, difficulty in swallowing, Hoarseness of voice, Tinnitus
, reduced hearing, Nasal regurgitation × 6 months
• MRI • 2.5 x2 cm, Brilliantly enhancing, extracranial lesion in Left jugular
foramen
• Hypo on T1 and Iso on T2
• Erosion of carotid canal and jugular foramen
• SURGERY • Excision of Glomus jugulare done by FISCH type approach
• BIOPSY • well defined nests separated by highly vascularized fibrous
septae[zelle ballen pattern]
• SRS • 14Gy/1#
• IHC • Synaptophysin positive
• S100 positive
• COURTESY • DR PSB
Case details
103

104. GTV WITH PTV 1MM
104

105. SRS PLAN
105

106. 6 month follow up- awaited
106

107. REMEMBERING THE LEGENDS
107

108. 108

109. 109

110. 110

111. 111

112. 112

113. 113

114. if you are thinking about me as legend
114

115. ACKNOWLEDGMENTS-CONSULTANTS
115
DR C R KUNDU DR P S BHATTACHARYYA
DR V K REDDY DR M MRUTYUNJAYA

116. ACKNOWLEDGMENTS- PHYSICISTS
116
A C PRABU A ANIL KUMAR A SRINU P PRASAD

117. ACKNOWLEDGMENTS- TECHNOLOGISTS
117

118. THE GUIDANCE
118

119. 119