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  1. 1. Treatment Modalities for Brain Disorders
  2. 2. Existing Treatment Modalities • Craniotomy • Chemotherapy • Brachytherapy • Whole brain radiation • XKnife • Fractionated linac treatment – radiotherapy • Gamma Knife® surgery – radiosurgery
  3. 3. Craniotomy – description A craniotomy is the surgical removal of a section of bone (bone flap) from the skull for the purpose of operating on the underlying tissues, usually the brain The bone flap is replaced at the end of the procedure Craniotomy is used for many different procedures within the head, including trauma, tumor, infection, aneurysm, etc.
  4. 4. Craniotomy – indications Size – tumor mass 3.5cm or larger Location – located on outer surface Patient age and health – able to withstand trauma of surgery Neurosurgeon’s familiarity and preference Used to treat: Brain tumors Blood clots Cerebral aneurysms AVMs Brain abscesses Head injury
  5. 5. Craniotomy – advantages • Complete and immediate removal of tumor • Provides access to disease site for brachytherapy or seed implantation • Improved outcomes when combined with follow- up Gamma Knife® surgery1 1 (Reference to come)
  6. 6. Craniotomy – disadvantages Higher incidence of mortality and morbidity than non-invasive treatment methods Requires strong surgical skill set acquired over time Significantly longer hospital stay and recovery time AVM resection may require up to 5 operations Reduced quality of life Greater incidence of complications and impaired brain functions Higher costs
  7. 7. Recovery time for craniotomy vs. radiosurgery
  8. 8. Chemotherapy – description • Chemotherapy refers to medicines that can kill or control cancer • Chemotherapy medicines target and treat a specific area affected by cancer • Chemotherapy is a systemic treatment, which means it is a treatment that affects the whole body • There are many kinds of chemotherapy, and the medicine chosen will depend on the type and the extent of the cancer, as well as the potential side effects of the medicine • Each medicine will have its own specific side effects
  9. 9. Chemotherapy – indications Chemotherapy is used to to control the growth of the cancer to relieve the symptoms or pain caused by the cancer Some types of cancer respond better to chemotherapy than others: Leukemia Lymphoma Breast cancer Colorectal cancer
  10. 10. Chemotherapy – advantages • Oral medication more convenient for patients (although also administered by shot) • Currently researching more effective treatments to effect cures at molecular level
  11. 11. Chemotherapy – disadvantages Can’t treat brain cancer effectively Chemotherapy affects both cancer cells and normal body tissues Most side effects are temporary and resolve when treatment ends Common complications include: Bone marrow suppression Hair loss Nausea Fatigue
  12. 12. Brachytherapy – description • Brachytherapy is a treatment method in which sealed radioactive seeds or sources are placed in or near tumors • The radioactive sources deliver high local doses of radiation to tumor cells while minimizing the dose to surrounding normal tissue • The depth of penetration of the emitted radiation, the type of radiation emitted, and the time course over which the radiation is delivered to achieve a particular dose are determined by the characteristics of the isotope selected
  13. 13. Brachytherapy – indications Recurrent or metastatic brain tumors Deliver treatment and minimize risk of damaging healthy tissue in patients who have already undergone external radiation therapy There are two primary ways of using brachytherapy in treating brain metastases Treat patients aggressively for an initial tumor Provide radiation boosts following external beam radiation or surgery
  14. 14. Brachytherapy – advantages • Use of brachytherapy in combination with other treatments which remove a substantial portion of the cancerous tumor offer promise • When a metastasis recurs, therapeutic options are limited; brachytherapy allows re-irradiation
  15. 15. Brachytherapy – disadvantages While less invasive delivery systems are being investigated, some sort of highly invasive surgical placement is currently required for placement of the radiation seed
  16. 16. Whole brain radiation – description Radiation therapy is a common treatment for brain tumors and can be combined with surgery or radiosurgery Radiation therapy affects both normal and tumor cells, but normal cells are thought to be more capable of repairing themselves As the therapy continues, the tumor cells should die and eventually shrink Radiation therapy does not remove the tumor
  17. 17. Whole brain radiation – indications Whole brain irradiation is frequently prescribed for patients with brain metastases After surgery for highly malignant tumors Instead of surgery for inoperable tumors Residual tumor after treatment
  18. 18. Whole brain radiation – advantages • Symptoms caused by metastatic tumors in the brain usually respond to whole brain radiation therapy • Different studies have reported response rates of 50 to 70 percent • Can attack microscopic disease not yet visible to current diagnostic studies
  19. 19. Whole brain radiation – combination • Stereotactic radiosurgery can be combined with whole brain radiation therapy for brain metastases • The whole brain radiation therapy will treat the visible metastases and any presumed microscopic tumor deposits as well • Whole brain radiation therapy is given as a low dose to a larger volume that includes the tumor as well as the area of possible tumor spread, while stereotactic radiosurgery is a high dose boost given to a very small volume and targeted only within the tumor itself • The two treatment techniques are complementary
  20. 20. Whole brain radiation – disadvantages Side effects will depend on the type of radiation received, the amount of the surface of the brain targeted, the site targeted and the total dose of radiation In general, there will be: hair loss, skin irritation, possible hearing problems, nausea, vomiting, loss of appetite and neurologic effects The most prevalent side effect is fatigue which may last through treatment and for many months afterwards The neurologic effects most affecting quality of life are memory and speech problems Radiation therapy is not recommended for young children as it may cause a deficit in intellectual development
  21. 21. Fractionated linac treatment – radiotherapy • About half of all patients with cancer are treated with radiotherapy and have a greater rate of success than chemotherapy, a lower risk of side effects and very few major side effects • Radiation or radiotherapy uses high-energy rays to kill cancer cells, shrink tumors and prevent cancer cells from growing and spreading • Radiation can be given internally (brachytherapy) or externally with the external beam being the most common type of radiation treatment
  22. 22. The difference between radiotherapy and radiosurgery Radiotherapy is an extended treatment program using fractionated radiation over multiple sessions Radiotherapy is the preferred solution for treating the body Radiosurgery is a single-session stereotactic procedure performed by a neurosurgeon-radiation oncologist team using radiation to destroy a target in the brain Radiosurgery is preferred for the brain and spine because it is a precise, single-dose procedure
  23. 23. Radiotherapy – advantages • The survival rate for patients with malignant tumors (e.g., anaplastic astrocytoma, glioblastoma multiform) more than doubles with radiation therapy, and it can prolong life for patients with low-grade gliomas as well
  24. 24. Radiotherapy – disadvantages Fractionated radiotherapy must be administered in multiple sessions rather than a single session like radiosurgery Radiotherapy devices are not as accurate as Leksell Gamma Knife® for targets in the brain
  25. 25. Radiotherapy machines Radiotherapy machines claiming efficacy for brain treatments include: • Accuray CyberKnife • BrainLab Novalis • Varian Trilogy
  26. 26. Accuray CyberKnife • Standard linac modified for use on head and spine • Accuracy is affected by the moving robotic arm • Patient movement will affect dose delivery outcome • Low output and lack of accuracy requires fractionated delivery • Only one beam size • Limited directions in which the robot can shoot • Not proven for small tumors or functional disorders
  27. 27. Brainlab Novalis • Standard linac modified for use on head and spine • Claims accuracy of 2mm • Low output, poor accuracy requires fractionated delivery • Up to 30 treatment sessions • Only one beam size • Limited directions in which the unit can shoot • Frameless design utilizes old mask-based fixation • Not proven for small tumors or functional disorders
  28. 28. Varian Trilogy • Standard linac modified for use on head and spine • Put into clinical operation in early 2005 • Claims accuracy of .75mm • “All-in-one unit” • Not proven for small tumors or functional disorders
  29. 29. Radionics XKnife• Standard linac modified for use on head and spine • No accuracy claims • Low output, poor accuracy requires fractionated delivery • Up to 30 treatment sessions • Only one beam size • Limited directions in which the unit can shoot • Frameless design utilizes old mask-based fixation • Not proven for small tumors or functional disorders
  30. 30. Elekta Leksell Gamma Knife® – radiosurgery
  31. 31. Elekta Leksell Gamma Knife® – description Leksell Gamma Knife® is a unique radiosurgery system dedicated to treating the most sensitive area in the body Non-invasive and gentle to the patient 201 stationary beams converge through four different collimators With the robotic Automatic Positioning system, Gamma Knife® can automatically hit multiple isocenters to precisely conform to the tumor shape Uses the head frame to co-register image studies to a frame-based study which are transferred into GammaPlan® treatment planning mode - helping to prevent mistakes and saving time
  32. 32. Elekta Leksell Gamma Knife® – indications Vascular disorders Benign tumors Malignant tumors Functional disorders Ocular disorders
  33. 33. Elekta Leksell Gamma Knife® – advantages • Can be used to treat metastases in surgically inaccessible areas of the brain, such as the brainstem • A noninvasive procedure performed on an outpatient basis is associated with less morbidity than surgery • Radiosurgery generally is more cost-effective than surgery • Radiosurgery is more accurate than radiotherapy
  34. 34. Elekta Leksell Gamma Knife® – accuracy Guaranteed accurate to 0.3mm for the life of the equipment Only equipment accurate enough to routinely treat functional disorders Tracks target 10 times per second Full MR compatibility Leksell® Coordinate Frame produces the best image quality and avoids movement artifacts, providing the highest reliability in patient precision
  35. 35. Elekta Leksell Gamma Knife® – proven radiosurgery success • Designed specifically to treat the brain • Unique delivery system uses 201 collimators for maximum accuracy • Single treatment session • Over 2000 published peer-reviewed papers • More than 300,000 patient treated • 15-year follow up study • Proven reliability and reproducibility • Single day surgery • Faster throughput in planning and treatment