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Jung H, Yoon J, Dona Lemus O, Tanny S, Zhou Y, Milano M, Usuki K, Hardy S, Zheng D. Dosimetric evaluation of LINAC-based single-isocenter multi-target multi-fraction stereotactic radiosurgery with more than 20 targets: comparing MME, HyperArc, and RapidArc. Radiat Oncol 2024; 19:19. [PMID: 38326813 PMCID: PMC10848506 DOI: 10.1186/s13014-024-02416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND To compare the dosimetric quality of three widely used techniques for LINAC-based single-isocenter multi-target multi-fraction stereotactic radiosurgery (fSRS) with more than 20 targets: dynamic conformal arc (DCA) in BrainLAB Multiple Metastases Elements (MME) module and volumetric modulated arc therapy (VMAT) using RapidArc (RA) and HyperArc (HA) in Varian Eclipse. METHODS Ten patients who received single-isocenter fSRS with 20-37 targets were retrospectively replanned using MME, RA, and HA. Various dosimetric parameters, such as conformity index (CI), Paddick CI, gradient index (GI), normal brain dose exposures, maximum organ-at-risk (OAR) doses, and beam-on times were extracted and compared among the three techniques. Wilcoxon signed-rank test was used for statistical analysis. RESULTS All plans achieved the prescribed dose coverage goal of at least 95% of the planning target volume (PTV). HA plans showed superior conformity compared to RA and MME plans. MME plans showed superior GI compared to RA and HA plans. RA plans resulted in significantly higher low and intermediate dose exposure to normal brain compared to HA and MME plans, especially for lower doses of ≥ 8Gy and ≥ 5Gy. No significant differences were observed in the maximum dose to OARs among the three techniques. The beam-on time of MME plans was about two times longer than RA and HA plans. CONCLUSIONS HA plans achieved the best conformity, while MME plans achieved the best dose fall-off for LINAC-based single-isocenter multi-target multi-fraction SRS with more than 20 targets. The choice of the optimal technique should consider the trade-offs between dosimetric quality, beam-on time, and planning effort.
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Affiliation(s)
- Hyunuk Jung
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA.
| | - Jihyung Yoon
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Olga Dona Lemus
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Sean Tanny
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Yuwei Zhou
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Michael Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Kenneth Usuki
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Sara Hardy
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
| | - Dandan Zheng
- Department of Radiation Oncology, University of Rochester, Rochester, NY, USA
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Bodensohn R, Maier SH, Belka C, Minniti G, Niyazi M. Stereotactic Radiosurgery of Multiple Brain Metastases: A Review of Treatment Techniques. Cancers (Basel) 2023; 15:5404. [PMID: 38001664 PMCID: PMC10670108 DOI: 10.3390/cancers15225404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
The advancement of systemic targeted treatments has led to improvements in the management of metastatic disease, particularly in terms of survival outcomes. However, brain metastases remain less responsive to systemic therapies, underscoring the significance of local interventions for comprehensive disease control. Over the past years, the threshold for treating brain metastases through stereotactic radiosurgery has risen. Yet, as the number of treated metastases increases, treatment complexity and duration also escalate. This trend has made multi-isocenter radiosurgery treatments, such as those with the Gamma Knife, challenging to plan and lengthy for patients. In contrast, single-isocenter approaches employing linear accelerators offer an efficient and expeditious treatment option. This review delves into the literature, comparing different linear-accelerator-based techniques with each other and in relation to dedicated systems, focusing on dosimetric considerations and feasibility.
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tübingen, Germany;
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Sebastian H. Maier
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (S.H.M.); (C.B.)
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (S.H.M.); (C.B.)
- German Cancer Consortium (DKTK), Partner Site Munich, A Partnership between DKFZ and LMU University Hospital, 81377 Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Giuseppe Minniti
- IRCCS Neuromed, 86077 Pozzilli, Italy;
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tübingen, Germany;
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, 72076 Tübingen, Germany
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (S.H.M.); (C.B.)
- German Cancer Consortium (DKTK), Partner Site Tübingen, A Partnership between DKFZ and University Hospital, 72076 Tübingen, Germany
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Thomson HM, Fortin Ensign SP, Edmonds VS, Sharma A, Butterfield RJ, Schild SE, Ashman JB, Zimmerman RS, Patel NP, Bryce AH, Vora SA, Sio TT, Porter AB. Clinical Outcomes of Stereotactic Radiosurgery-Related Radiation
Necrosis in Patients with Intracranial Metastasis from Melanoma. Clin Med Insights Oncol 2023; 17:11795549231161878. [PMID: 36968334 PMCID: PMC10034291 DOI: 10.1177/11795549231161878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/19/2023] [Indexed: 03/24/2023] Open
Abstract
Background: Radiation necrosis (RN) is a clinically relevant complication of stereotactic
radiosurgery (SRS) for intracranial metastasis (ICM) treatments. Radiation
necrosis development is variable following SRS. It remains unclear if risk
factors for and clinical outcomes following RN may be different for melanoma
patients. We reviewed patients with ICM from metastatic melanoma to
understand the potential impact of RN in this patient population. Methods: Patients who received SRS for ICM from melanoma at Mayo Clinic Arizona
between 2013 and 2018 were retrospectively reviewed. Data collected included
demographics, tumor characteristics, radiation parameters, prior surgical
and systemic treatments, and patient outcomes. Radiation necrosis was
diagnosed by clinical evaluation including brain magnetic resonance imaging
(MRI) and, in some cases, tissue evaluation. Results: Radiation necrosis was diagnosed in 7 (27%) of 26 patients at 1.6 to 38
months following initial SRS. Almost 92% of all patients received systemic
therapy and 35% had surgical resection prior to SRS. Patients with RN
trended toward having larger ICM and a prior history of surgical resection,
although statistical significance was not reached. Among patients with
resection, those who developed RN had a longer period between surgery and
SRS start (mean 44 vs 33 days). Clinical improvement following treatment for
RN was noted in 2 (29%) patients. Conclusions: Radiation necrosis is relatively common following SRS for treatment of ICM
from metastatic melanoma and clinical outcomes are poor. Further studies
aimed at mitigating RN development and identifying novel approaches for
treatment are warranted.
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Affiliation(s)
- Holly M Thomson
- Department of Internal Medicine, Mayo
Clinic, Phoenix, AZ, USA
| | | | | | - Akanksha Sharma
- Department of Neurology, Pacific
Neurosciences Institute and John Wayne Cancer Center, Santa Monica, CA, USA
| | | | - Steven E Schild
- Department of Radiation Oncology, Mayo
Clinic, Phoenix, AZ, USA
| | | | | | - Naresh P Patel
- Department of Neurosurgery, Mayo
Clinic, Phoenix, AZ, USA
| | - Alan H Bryce
- Department of Hematology and Oncology,
Mayo Clinic, Phoenix, AZ, USA
| | - Sujay A Vora
- Department of Radiation Oncology, Mayo
Clinic, Phoenix, AZ, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo
Clinic, Phoenix, AZ, USA
| | - Alyx B Porter
- Department of Hematology and Oncology,
Mayo Clinic, Phoenix, AZ, USA
- Department of Neurology, College of
Medicine, Mayo Clinic, Phoenix, AZ, USA
- Alyx B Porter, Department of Neurology,
College of Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.
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Albers EAC, de Ruiter MB, van de Poll-Franse LV, Merckel LG, Compter A, Schagen SB. Neurocognitive functioning after Gamma Knife and LINAC stereotactic radiosurgery in patients with brain metastases. J Neurooncol 2022; 160:649-658. [PMID: 36454373 PMCID: PMC9713121 DOI: 10.1007/s11060-022-04185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/26/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE Brain metastases (BM) themselves and treatment with stereotactic radiosurgery (SRS) can influence neurocognitive functioning. This prospective study aimed to assess neurocognitive decline in patients with BM after SRS. METHODS A neuropsychological test battery was assessed yielding ten test outcomes. Neurocognitive decline at 3 and 6 months post SRS was compared to measurement prior to Gamma Knife (GK) or linear accelerator (LINAC) SRS. Reliable change indices with correction for practice effects were calculated to determine the percentage of neurocognitive decline (defined as decline on ≥ 2 test outcomes). Risk factors of neurocognitive decline were analyzed with binary logistic regression. RESULTS Of 194 patients pre-SRS, 40 GK and 29 LINAC patients had data accessible at 6 months. Compared to baseline, 38% of GK patients declined at 3 months, and 23% declined at 6 months. GK patients declined on attention, executive functioning, verbal memory, and fine motor skill. Of LINAC patients, 10% declined at 3 months, and 24% at 6 months. LINAC patients declined on executive functioning, verbal memory, and fine motor skills. Risk factors of neurocognitive decline at 3 months were high age, low education level and type of SRS (GK or LINAC). At 6 months, high age was a risk factor. Karnofsky Performance Scale, BM volume, number of BM, tumor progression and neurocognitive impairment pre-SRS were no risk factors. CONCLUSION Neurocognitive decline occurs in a considerable proportion of patients with BM treated with GK or LINAC SRS. Overall, high age appears to be a risk factor for neurocognitive decline after SRS.
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Affiliation(s)
- Elaine A C Albers
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - Michiel B de Ruiter
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, Centre of Research on Psychological and Somatic Disorders (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Laura G Merckel
- Department of Radiotherapy, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Annette Compter
- Department of Neuro-Oncology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Sanne B Schagen
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
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Hunte SO, Clark CH, Zyuzikov N, Nisbet A. Volumetric modulated arc therapy (VMAT): a review of clinical outcomes—what is the clinical evidence for the most effective implementation? Br J Radiol 2022; 95:20201289. [PMID: 35616646 PMCID: PMC10162061 DOI: 10.1259/bjr.20201289] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Modern conformal radiation therapy using techniques such as modulation, image guidance and motion management have changed the face of radiotherapy today offering superior conformity, efficiency, and reproducibility to clinics worldwide. This review assesses the impact of these advanced radiotherapy techniques on patient toxicity and survival rates reported from January 2017 to September 2020. The main aims are to establish if dosimetric and efficiency gains correlate with improved survival and reduced toxicities and to answer the question ‘What is the clinical evidence for the most effective implementation of VMAT?’. Compared with 3DCRT, improvements have been reported with VMAT in prostate, locally advanced cervical carcinoma and various head and neck applications, leading to the shift in technology to VMAT. Other sites such as thoracic neoplasms and nasopharyngeal carcinomas have observed some improvement with VMAT although not in line with improved dosimetric measures, and the burden of toxicity and the incidence of cancer related deaths remain high, signaling the need to further mitigate toxicity and increase survival. As technological advancement continues, large randomised long-term clinical trials are required to determine the way-forward and offer site-specific recommendations. These studies are usually expensive and time consuming, therefore utilising pooled real-world data in a prospective nature can be an alternative solution to comprehensively assess the efficacy of modern radiotherapy techniques.
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Affiliation(s)
- Sherisse Ornella Hunte
- Radiotherapy Department, Cancer Centre of Trinidad and Tobago, St James, Trinidad and Tobago
- University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Catharine H Clark
- Radiotherapy Physics, UCLH NHS Foundation Trust, London, UK
- Metrology for Medical Physics National Physical Laboratory, Teddington, UK
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | | | - Andrew Nisbet
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
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Saglam Y, Samanci Y, Bolukbasi Y, Peker S. Dosimetric comparison of volumetric modulated arc therapy with TrueBeam LINAC and hypofractionated radiosurgery with gamma knife ICON for large (>10 cm3) skull base meningiomas. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2022; 30:1201-1211. [PMID: 36189527 DOI: 10.3233/xst-221264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Multi Fractionated stereotactic radiosurgery (MF-SRS) of Linac has an essential role in the treatment of skull base meningiomas (sbMNG). However, Gamma Knife Icon (GK) allows MF-SRS using mask immobilization with onboard image guidance. OBJECTIVE This dosimetric study aims to investigate whether equivalent plan quality can be achieved with Volumetric Modulated Arc Therapy (VMAT) in patients with large sbMNG (>10 cm3) previously treated with GK. METHODS Twenty patients with the median target volume of 19.7cm3 are re-planned by using VMAT with 20 Gy in 5 fractions. Plan qualities are compared to tumor coverage, paddick conformity index (PCI), gradient index (GI), V4 Gy, V10 Gy, V12 Gy, optic chiasm V20 Gy, brainstem V23 Gy, optic nerve V25 Gy volumes, and maximum doses for all. Additionally, beam-on time and approximate planning time are also analyzed and compared. RESULTS All plans provide adequate clinical requirements. First, the CI is comparable for the GK and VMAT (0.99±0.01 vs. 1.13±0.20; p = 0.18). Second, VMAT has a significantly higher GI than GK (3.81±0.35 vs. 2.63±0.09; p < 0.001). Third, the PCI is significantly higher in GK than VMAT (0.76±0.05 vs. 0.70±0.07; p < 0.001). The lower GI of the GK also results in significantly lower V4 Gy (156.1±43.8 vs. 207.5±40.1 cm3, p < 0.001) and V10 Gy (26.1±9.0 vs. 28.9±7.7 cm3, p < 0.001) compared to VMAT. Last, the VMAT reduces beam-on time (4.8±0.5 vs. 19±1.1 min.; p < 0.001). CONCLUSION Although both systems have succeeded in creating effective plans in clinical practice, the GK reveals more effective lower normal brain tissue doses. However, the shorter treatment time with LINAC, excluding the total procedure time, can be considered advantageous over GK.
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Affiliation(s)
- Yucel Saglam
- Department of Radiation Oncology, Koc University, School of Medicine, Davutpasa Caddesi, Topkapi, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University, School of Medicine, Davutpasa Caddesi, Topkapi, Istanbul, Turkey
| | - Yasemin Bolukbasi
- Department of Radiation Oncology, Koc University, School of Medicine, Davutpasa Caddesi, Topkapi, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, Koc University, School of Medicine, Davutpasa Caddesi, Topkapi, Istanbul, Turkey
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Zhou H, Wu T, Zhu X, Li Y. Re-irradiation of multiple brain metastases using CyberKnife stereotactic radiotherapy: Case report. Medicine (Baltimore) 2021; 100:e27543. [PMID: 34731155 PMCID: PMC8519193 DOI: 10.1097/md.0000000000027543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/01/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Brain metastasis (BM) is the commonest adult intracranial malignancy and many patients with brain metastases require two course radiotherapy. Re-irradiation is frequently performed in Radiotherapy (RT) departments for multiple brain metastases. PATIENT CONCERNS We present a case of a 55-year-old male patient suffering from brain metastases, who had previously received whole-brain radiotherapy (WBRT) and first CyberKnife Stereotactic Radiotherapy (CKSRT) for metastases, presented with a recurrence of metastasis and new lesions in the brain. DIAGNOSES An enhanced computed tomography (CT) scan of the brain revealed abnormalities with double-dosing of intravenous contrast that identified >10 lesions scattered in the whole brain. INTERVENTIONS Re-irradiation was performed using CKSRT. The patient was treated with 30 Gy in 5 fractions for new lesions and 25 Gy in 5 fractions for lesion that were locally recurrent and close to brainstem lesions. OUTCOME The lesions were well-controlled, and the headache of the patient was significantly relieved one month after radiotherapy. The total survival time of the patients was 17 months from the beginning of the Cyberknife treatment. CONCLUSION The present case report demonstrates that CyberKnife therapy plays a significant role in the repeated radiotherapy for multiple metastatic brain tumors. CKSRT can be used as a salvage method in recurrent multiple brain metastases.
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Affiliation(s)
- Han Zhou
- School of Electronic Science and Engineering, Nanjing University, Nanjing, China
- Department of Radiation Oncology The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Tiancong Wu
- Department of Radiation Oncology, Jinling hospital, Jiangsu, China
| | - Xixu Zhu
- Department of Radiation Oncology, Jinling hospital, Jiangsu, China
| | - Yikun Li
- Department of Radiation Oncology, Jinling hospital, Jiangsu, China
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8
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Myrehaug S, Hudson J, Soliman H, Ruschin M, Tseng CL, Detsky J, Husain Z, Keith J, Atenafu EG, Maralani P, Heyn C, Das S, Lipsman N, Sahgal A. Hypofractionated Stereotactic Radiation Therapy for Intact Brain Metastases in 5 Daily Fractions: Effect of Dose on Treatment Response. Int J Radiat Oncol Biol Phys 2021; 112:342-350. [PMID: 34537313 DOI: 10.1016/j.ijrobp.2021.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Multileaf collimator (MLC) linear accelerator (Linac)-based hypofractionated stereotactic radiation therapy (HSRT) is increasingly used not only for large brain metastases or those adjacent to critical structures but also for those metastases that would otherwise be considered for single-fraction radiosurgery (SRS). However, data on outcomes in general are limited, and there is a lack of understanding regarding optimal dosing. Our aim was to report mature image-based outcomes for MLC-Linac HSRT with a focus on clinical and dosimetric factors associated with local failure (LF). METHODS AND MATERIALS A total of 220 patients with 334 brain metastases treated with HSRT were identified. All patients were treated using a 5-fraction daily regimen and were followed with clinical evaluation and volumetric magnetic resonance imaging every 2 to 3 months. Overall survival and progression-free survival were calculated using the Kaplan-Meier method, with LF determined using Fine and Gray's competing risk method. Predictive factors were identified using Cox regression multivariate analysis. RESULTS Median follow-up was 10.8 months. Median size of treated metastasis was 1.9 cm; 60% of metastases were <2 cm in size. The median total dose was 30 Gy in 5 fractions; 36% of the cohort received <30 Gy. The median time to LF and 12-month cumulative incidence of LF was 8.5 months and 23.8%, respectively. Median time to death and 12-month overall survival rates were 11.8 months and 48.2%, respectively. Fifty-two metastases (15.6%) had an adverse radiation effect, of which 32 (9.5%) were symptomatic necrosis. Multivariable analysis identified worse LF in patients who received a total dose of <30 Gy (hazard ratio, 1.62; P = .03), with LF at 6 and 12 months of 13% and 33% for patients treated with <30 Gy versus 5% and 19% for patients treated with >30 Gy. Exploratory analysis demonstrated a dose-response effect observed in all histologic types, including among breast cancer subtypes. CONCLUSION Optimal local control is achieved with HSRT of ≥30 Gy in 5 daily fractions, independent of tumor volume and histology, with an acceptable risk of radiation necrosis.
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Affiliation(s)
- Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada.
| | - John Hudson
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Mark Ruschin
- Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michaels Hospital, Ontario, Canada
| | - Nir Lipsman
- Department of Neurosurgery, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
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Veselsky T, Syruckova T, Kindlova A, Osmancikova P. Pituitary adenoma treatment plan quality comparison between linear accelerator volumetric modulated arc therapy and Leksell Gamma Knife® radiosurgery. Med Dosim 2021; 46:440-448. [PMID: 34312022 DOI: 10.1016/j.meddos.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/16/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
The aim of this study was to compare radiosurgical treatment plan quality of a linear accelerator with Leksell Gamma Knife (LGK) for pituitary adenoma irradiation. Thirty pituitary adenoma patients were evaluated in this study. Treatment plans were prepared on LGK and stereotactic linear accelerator Varian TrueBeam STx. Volumetric Modulated Arc Therapy (VMAT) plans (21 plans with 2 coplanar arcs and 9 plans with 4 non-coplanar arcs) were calculated for linear accelerator. All the plans were evaluated in terms of conformity, selectivity, gradient index and organ at risk (OAR) sparing. VMAT produced dosimetrically comparable treatment plans to LGK regarding conformity and selectivity (New Conformity Index (NCI): 1.76 ± 0.65 for 4 arc VMAT, 2.33 ± 1,16 for 2 arc VMAT and 1.96 ± 0.71 for LGK; Selectivity Index (SI): 0.63 ± 0.16 for 4 arc VMAT, 0.51 ± 0.16 for 2 arc VMAT and 0.58 ± 0.17 for LGK). Gradient index (GI) was superior for LGK plans (GI: 2.74 ± 0.20 for LGK and 5.28 ± 2.29 for 4 arc VMAT). OAR sparing for optics, brainstem, and hypophysis was similar for both modalities while target volume coverage was maintained the same. Finally, treatment time resulted in favor of VMAT plans (in this study VMAT plans were almost 5 times faster than LGK treatment regarding beam on time). According to the results of this study stereotactic linear accelerator with VMAT treatment could be used as a reasonable alternative to LGK for pituitary adenoma radiosurgery but only if the same head fixation method accuracy and target volume delineation are maintained for both modalities.
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Affiliation(s)
- T Veselsky
- Motol University Hospital, Oncology Clinic, Prague 5, Czech Republic; Military University Hospital, Department of Radiation Therapy, Prague 6, Czech Republic; Na Homolce Hospital, Medical Physics Department, Prague 5, Czech Republic.
| | - T Syruckova
- Czech Technical University in Prague, Faculty of Biomedical Engineering, Kladno, Czech Republic
| | - A Kindlova
- Motol University Hospital, Oncology Clinic, Prague 5, Czech Republic
| | - P Osmancikova
- Motol University Hospital, Oncology Clinic, Prague 5, Czech Republic; Czech Technical University in Prague, Faculty of Nuclear Sciences and Physical Engineering, Department of Dosimetry and Application of Ionizing Radiation, Prague 110 00, Czech Republic
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10
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Lai J, Liu J, Zhao J, Li A, Liu S, Deng Z, Tan Q, Wang H, Jia Y, Lei K, Zhou L. Effective method to reduce the normal brain dose in single-isocenter hypofractionated stereotactic radiotherapy for multiple brain metastases. Strahlenther Onkol 2021; 197:592-600. [PMID: 33725135 DOI: 10.1007/s00066-021-01757-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/15/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Island blocking and dose leakage problems will lead to unnecessary irradiation to normal brain tissue (NBT) in hypofractionated stereotactic radiotherapy (HSRT) for multiple brain metastases (BM) with single-isocenter volumetric modulated arc therapy (VMAT). The present study aimed at investigating whether reducing the number of metastases irradiated by each arc beam could minimize these two problems. MATERIALS AND METHODS A total of 32 non-small-cell lung cancer (NSCLC) patients with multiple BM received HSRT (24-36 Gy/3 fractions) with single-isocenter VMAT, where each arc beam only irradiated partial metastases (pm-VMAT), were enrolled in this retrospective study. Conventional single-isocenter VMAT plans, where each arc beam irradiated whole metastases (wm-VMAT), was regenerated and compared with pm-VMAT plans. Furthermore, the clinical efficacy and toxicities were evaluated. RESULTS Pm-VMAT achieved similar target coverage as that with wm-VMAT, with better dose fall-off (P < 0.001) and NBT sparing (P < 0.001). However, pm-VMAT resulted in more monitor units (MU) and longer beam-on time (P < 0.001). The intracranial objective response rate and disease control rate for all patients were 75% and 100%, respectively. The local control rates at 1 year and 2 year were 96.2% and 60.2%, respectively. The median progression-free survival and overall survival were 10.3 months (95% confidence interval [CI] 6.8-13.2) and 18.5 months (95% CI 15.9-20.1), respectively. All treatment-related adverse events were grade 1 or 2, and 3 lesions (2.31%) from 2 patients (6.25%) demonstrated radiation necrosis after HSRT. CONCLUSION HSRT with pm-VMAT is effective and has limited toxicities for NSCLC patients with multiple BM. Pm-VMAT could provide better NBT sparing while maintaining target dose coverage.
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Affiliation(s)
- Jialu Lai
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - Jia Liu
- Department of Oncology, Chengdu First People' Hospital, 18, Wanxiang North Road, 610041, Chengdu, Sichuan, China
| | - Jianling Zhao
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - An Li
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - Shoupeng Liu
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - Zhonghua Deng
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - Qiaoyue Tan
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - Haitao Wang
- Department of Radiotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China
| | - Yuming Jia
- Department of Oncology, Yibin Second People' Hospital, 96, North Street, 644000, Yibin, Sichuan, China
| | - Kaijian Lei
- Department of Oncology, Yibin Second People' Hospital, 96, North Street, 644000, Yibin, Sichuan, China
| | - Lin Zhou
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, 37, Guoxue Lane, 610041, Chengdu, Sichuan, China.
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11
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Liu CW, Ahmed S, Gray T, Ma T, Cho YB, Neyman G, Chao S, Suh J, Xia P. Is there a volume threshold of brain metastases for Linac-based stereotactic radiotherapy? JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:309-319. [PMID: 34631232 PMCID: PMC8492046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/17/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE To investigate whether there is a volume threshold in target volume of brain metastases below which a small cone size and sharp penumbra in Gamma Knife (GK) may provide improved plan quality when compared to Volumetric Modulated Arc Therapy (VMAT)-based stereotactic radiosurgery (SRS). METHODS For patients treated on GK SRS for brain metastases in 2018-2019 in our institution, 121 patients with two and three targets were identified. Twenty-six patients with two or three brain metastases (total of 76 lesions) were selected for this study. Two VMAT plans, SmartArc (Pinnacle) and HyperArc (Eclipse), were generated retrospectively for each patient. Plan quality was evaluated based on RTOG conformity index (CI), Paddick gradient index (GI), normal tissue (NT) V12Gy and V4.5Gy. By using the receiver operating characteristic (ROC) curve for both VMAT plans (SmartArc and HyperArc) and metrics of RTOG CI and NT V12Gy, we compared GK plans to SmartArc and HyperArc plans separately to determine the threshold volume. RESULTS For SmartArc plans, both ROC curve analyses showed a threshold volume of 0.4 cc for both CI and NT V12Gy. For HyperArc plans, the threshold volumes were 0.2 cc for the CI and 0.5 cc for NT V12Gy. GK plans produced improved dose distribution compared to VMAT for targets ≤0.4 cc, but HyperArc was found to have competing results with GK in terms of CI and NT V12Gy. For targets > 0.4 cc, both SmartArc and HyperArc showed better plan quality when compared to the GK plans. CONCLUSIONS Target volumes ≤0.4 cc may require a small cone size and sharp penumbra in GK while for target volumes >0.4 cc, VMAT-based SRS can provide improved overall plan quality and faster treatment delivery.
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Affiliation(s)
- Chieh-Wen Liu
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Saeed Ahmed
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Tara Gray
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Tianjun Ma
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Young-Bin Cho
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Gennady Neyman
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Samuel Chao
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - John Suh
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Ping Xia
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
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12
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Bossart E, Mellon EA, Monterroso I, Elsayyad N, Diwanji T, Samuels S, Dogan N. Assessment of single isocenter linear accelerator radiosurgery for metastases and base of skull lesions. Phys Med 2020; 81:1-8. [PMID: 33278764 DOI: 10.1016/j.ejmp.2020.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/22/2020] [Accepted: 11/07/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Newer technology for stereotactic radiosurgery (SRS) should be assessed for different multi-leaf collimators (MLC). OBJECTIVE Assess plan quality of an automated, frameless, linear accelerator based (linac) planning and delivery system (HyperArc) for SRS using both standard MLC (SMLC) and high definition MLC (HDMLC) compared to a cobalt-60 based SRS system (Gamma Knife, GK). METHODS We re-planned twenty GK Perfexion-treated SRS patients (27 lesions) for HyperArc using SMLC and HDMLC. We assessed plan quality using the following metrics: gradient index (GI), Paddick and RTOG conformity indices (CIPaddick, CIRTOG), volume receiving half of prescription isodose (PIVhalf) and maximum dose to 0.03 cc for brainstem, optic chiasm and optic nerves, and V12Gy for brain-GTV. RESULTS Linac plans had better conformity with HDMLC being most conformal. GK exhibited better GI. PIVhalf demonstrated no statistically significant difference between HDMLC and GK, and SMLC was nominally worse than GK. Mean PIVhalf was generally 0.85 cc larger for SMLC than HDMLC. For TV > 1.0 cc, the relative differences in CIRTOG, GI, and PIVhalf for SMLC vs. HDMLC were less than 21%. For TV less than < 1.0 cc, there were more obvious relative differences for SMLC vs. HDMLC in CIRTOG (mean 146%, max 700%), GI (mean 49%, max 162%), and PIVhalf (mean 77%, max 522%). Organ at risk doses were met in all plans. CONCLUSIONS New linac-based plans positively compare to GK plans overall. HDMLC should be strongly considered for treatment of lesions < 1.0 cc given the significant improvements in conformity and PIVhalf over SMLC.
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Affiliation(s)
- Elizabeth Bossart
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irene Monterroso
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nagy Elsayyad
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stuart Samuels
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nesrin Dogan
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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13
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El Shafie RA, Tonndorf-Martini E, Schmitt D, Celik A, Weber D, Lang K, König L, Höne S, Forster T, von Nettelbladt B, Adeberg S, Debus J, Rieken S, Bernhardt D. Single-Isocenter Volumetric Modulated Arc Therapy vs. CyberKnife M6 for the Stereotactic Radiosurgery of Multiple Brain Metastases. Front Oncol 2020; 10:568. [PMID: 32457829 PMCID: PMC7225280 DOI: 10.3389/fonc.2020.00568] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/30/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction: Stereotactic radiosurgery (SRS) is becoming more frequently used for patients with multiple brain metastases (BMs). Single-isocenter volumetric modulated arc therapy (SI-VMAT) is an emerging alternative to dedicated systems such as CyberKnife (CK). We present a dosimetric comparison between CyberKnife M6 and SI-VMAT, planned at RayStation V8B, for the simultaneous SRS of five or more BM. Patients and Methods: Twenty treatment plans of CK-based single-session SRS to ≥5 brain metastases were replanned using SI-VMAT for delivery at an Elekta VersaHD linear accelerator. Prescription dose was 20 or 18 Gy, conformally enclosing at least 98% of the total planning target volume (PTV), with PTV margin-width adapted to the respective SRS technique. Comparatively analyzed quality metrics included dose distribution to the healthy brain (HB), including different isodose volumes, conformity, and gradient indices. Estimated treatment time was also compared. Results: Median HB isodose volumes for 3, 5, 8, 10, and 12 Gy were consistently smaller for CK-SRS compared to SI-VMAT (p < 0.001). Dose falloff outside the target volume, as expressed by the gradient indices GI_high and GI_low, was consistently steeper for CK-SRS compared to SI-VMAT (p < 0.001). CK-SRS achieved a median GI_high of 3.1 [interquartile range (IQR), 2.9–1.3] vs. 5.0 (IQR 4.3–5.5) for SI-VMAT (p < 0.001). For GI_low, the results were 3.0 (IQR, 2.9–3.1) for CK-SRS vs. 5.6 (IQR, 4.3–5.5) for SI-VMAT (p < 0.001). The median conformity index (CI) was 1.2 (IQR, 1.1–1.2) for CK-SRS vs. 1.5 (IQR, 1.4–1.7) for SI-VMAT (p < 0.001). Estimated treatment time was shorter for SI-VMAT, yielding a median of 13.7 min (IQR, 13.5–14.0) compared to 130 min (IQR, 114.5–154.5) for CK-SRS (p < 0.001). Conclusion: SI-VMAT offers enhanced treatment efficiency in cases with multiple BM, as compared to CyberKnife, but requires compromise regarding conformity and integral dose to the healthy brain. Additionally, delivery at a conventional linear accelerator (linac) may require a larger PTV margin to account for delivery and setup errors. Further evaluations are warranted to determine whether the detected dosimetric differences are clinically relevant. SI-VMAT could be a reasonable alternative to a dedicated radiosurgery system for selected patients with multiple BM.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Eric Tonndorf-Martini
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Daniela Schmitt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Aylin Celik
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Simon Höne
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Bastian von Nettelbladt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
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14
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Han EY, Wang H, Luo D, Li J, Wang X. Dosimetric comparison of fractionated radiosurgery plans using frameless Gamma Knife ICON and CyberKnife systems with linear accelerator-based radiosurgery plans for multiple large brain metastases. J Neurosurg 2020; 132:1473-1479. [PMID: 30952125 DOI: 10.3171/2019.1.jns182769] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For patients with multiple large brain metastases with at least 1 target volume larger than 10 cm3, multifractionated stereotactic radiosurgery (MF-SRS) has commonly been delivered with a linear accelerator (LINAC). Recent advances of Gamma Knife (GK) units with kilovolt cone-beam CT and CyberKnife (CK) units with multileaf collimators also make them attractive choices. The purpose of this study was to compare the dosimetry of MF-SRS plans deliverable on GK, CK, and LINAC and to discuss related clinical issues. METHODS Ten patients with 2 or more large brain metastases who had been treated with MF-SRS on LINAC were identified. The median planning target volume was 18.31 cm3 (mean 21.31 cm3, range 3.42-49.97 cm3), and the median prescribed dose was 27.0 Gy (mean 26.7 Gy, range 21-30 Gy), administered in 3 to 5 fractions. Clinical LINAC treatment plans were generated using inverse planning with intensity modulation on a Pinnacle treatment planning system (version 9.10) for the Varian TrueBeam STx system. GK and CK planning were retrospectively performed using Leksell GammaPlan version 10.1 and Accuray Precision version 1.1.0.0 for the CK M6 system. Tumor coverage, Paddick conformity index (CI), gradient index (GI), and normal brain tissue receiving 4, 12, and 20 Gy were used to compare plan quality. Net beam-on time and approximate planning time were also collected for all cases. RESULTS Plans from all 3 modalities satisfied clinical requirements in target coverage and normal tissue sparing. The mean CI was comparable (0.79, 0.78, and 0.76) for the GK, CK, and LINAC plans. The mean GI was 3.1 for both the GK and the CK plans, whereas the mean GI of the LINAC plans was 4.1. The lower GI of the GK and CK plans would have resulted in significantly lower normal brain volumes receiving a medium or high dose. On average, GK and CK plans spared the normal brain volume receiving at least 12 Gy and 20 Gy by approximately 20% in comparison with the LINAC plans. However, the mean beam-on time of GK (∼ 64 minutes assuming a dose rate of 2.5 Gy/minute) plans was significantly longer than that of CK (∼ 31 minutes) or LINAC (∼ 4 minutes) plans. CONCLUSIONS All 3 modalities are capable of treating multiple large brain lesions with MF-SRS. GK has the most flexible workflow and excellent dosimetry, but could be limited by the treatment time. CK has dosimetry comparable to that of GK with a consistent treatment time of approximately 30 minutes. LINAC has a much shorter treatment time, but residual rotational error could be a concern.
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Affiliation(s)
| | - He Wang
- Departments of1Radiation Physics and
| | | | - Jing Li
- 2Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xin Wang
- Departments of1Radiation Physics and
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15
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Flattening filter free beam energy selection and its impact in multitarget intracranial stereotactic radiosurgery treatments. Med Dosim 2020; 45:363-367. [DOI: 10.1016/j.meddos.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/08/2020] [Accepted: 05/10/2020] [Indexed: 11/22/2022]
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16
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Zhang S, Yang R, Wang X. Dosimetric quality and delivery efficiency of robotic radiosurgery for brain metastases: Comparison with C-arm linear accelerator based plans. J Appl Clin Med Phys 2019; 20:104-110. [PMID: 31580532 PMCID: PMC6839388 DOI: 10.1002/acm2.12746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/25/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022] Open
Abstract
The incidence of brain metastases is increasing and various treatment modalities exist for brain metastases. The aim of this study was to investigate the dosimetric quality and delivery efficiency of robotic radiosurgery (CyberKnife) for multiple brain metastases compared with C‐arm linear accelerator (linac) based plans. C‐arm linac based plans included intensity‐modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) and non‐coplanar VMAT with 1, 3 and 5 non‐coplanar arcs, respectively (NC1, NC3 and NC5). For 20 patients, six plans with a prescription dose of 30 Gy in three fractions were generated. The gradient index (GI), conformity index (CI), maximum dose (Dmax) of organs at risk (OARs), normal brain tissue volume (V3 Gy–V24 Gy), monitor units (MUs) and beam on time (BT) were evaluated. The GI of CyberKnife plans (3.60 ± 0.70) was lower than IMRT (6.21 ± 2.26, P < 0.05), VMAT (6.04 ± 1.93, P < 0.05), NC1 (5.16 ± 1.71, P < 0.05), NC3 (5.02 ± 1.59, P < 0.05) and NC5 (5.03 ± 1.72, P < 0.05). The CI of the VMAT plans (both coplanar and non‐coplanar) was larger than IMRT and CK plans. The Dmax for most OARs of the CyberKnife plan was lower than the C‐arm linac based plans, although some differences were not statistically significant. The normal brain tissue volume of CyberKnife plan was lower than the C‐arm linac based plans, and the normal brain tissue volume of non‐coplanar VMAT plans was lower than IMRT and VMAT plans at high‐moderate dose level. However, the MUs and BT of CyberKnife plans was more than C‐arm linac based plans. CyberKnife plan was better than C‐arm linac based plans in protecting normal brain tissue and OARs for patients with multiple brain metastases. C‐arm linac based plan with non‐coplanar arc provided better protection of normal brain tissue than coplanar plan. However, the BT of CyberKnife plan was longer than C‐arm linac based plans.
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Affiliation(s)
- Shuming Zhang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ruijie Yang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Xin Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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Vergalasova I, Liu H, Alonso-Basanta M, Dong L, Li J, Nie K, Shi W, Teo BKK, Yu Y, Yue NJ, Zou W, Li T. Multi-Institutional Dosimetric Evaluation of Modern Day Stereotactic Radiosurgery (SRS) Treatment Options for Multiple Brain Metastases. Front Oncol 2019; 9:483. [PMID: 31231614 PMCID: PMC6568036 DOI: 10.3389/fonc.2019.00483] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/21/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose/Objectives: There are several popular treatment options currently available for stereotactic radiosurgery (SRS) of multiple brain metastases: 60Co sources and cone collimators around a spherical geometry (GammaKnife), multi-aperture dynamic conformal arcs on a linac (BrainLab Elements™ v1.5), and volumetric arc therapy on a linac (VMAT) calculated with either the conventional optimizer or with the Varian HyperArc™ solution. This study aimed to dosimetrically compare and evaluate the differences among these treatment options in terms of dose conformity to the tumor as well as dose sparing to the surrounding normal tissues. Methods and Materials: Sixteen patients and a total of 112 metastases were analyzed. Five plans were generated per patient: GammaKnife, Elements, HyperArc-VMAT, and two Manual-VMAT plans to evaluate different treatment planning styles. Manual-VMAT plans were generated by different institutions according to their own clinical planning standards. The following dosimetric parameters were extracted: RTOG and Paddick conformity indices, gradient index, total volume of brain receiving 12Gy, 6Gy, and 3Gy, and maximum doses to surrounding organs. The Wilcoxon signed rank test was applied to evaluate statistically significant differences (p < 0.05). Results: For targets ≤ 1 cm, GammaKnife, HyperArc-VMAT and both Manual-VMAT plans achieved comparable conformity indices, all superior to Elements. However, GammaKnife resulted in the lowest gradient indices at these target sizes. HyperArc-VMAT performed similarly to GammaKnife for V12Gy parameters. For targets ≥ 1 cm, HyperArc-VMAT and Manual-VMAT plans resulted in superior conformity vs. GammaKnife and Elements. All SRS plans achieved clinically acceptable organs-at-risk dose constraints. Beam-on times were significantly longer for GammaKnife. Manual-VMATA and Elements resulted in shorter delivery times relative to Manual-VMATB and HyperArc-VMAT. Conclusion: The study revealed that Manual-VMAT and HyperArc-VMAT are capable of achieving similar low dose brain spillage and conformity as GammaKnife, while significantly minimizing beam-on time. For targets smaller than 1 cm in diameter, GammaKnife still resulted in superior gradient indices. The quality of the two sets of Manual-VMAT plans varied greatly based on planner and optimization constraint settings, whereas HyperArc-VMAT performed dosimetrically superior to the two Manual-VMAT plans.
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Affiliation(s)
- Irina Vergalasova
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Haisong Liu
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Jun Li
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Ke Nie
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Yan Yu
- Department of Radiation Oncology, Thomas Jefferson University Kimmel Cancer Center, Philadelphia, PA, United States
| | - Ning Jeff Yue
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
| | - Taoran Li
- Department of Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, United States
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18
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Pre-Operative Versus Post-Operative Radiosurgery of Brain Metastases-Volumetric and Dosimetric Impact of Treatment Sequence and Margin Concept. Cancers (Basel) 2019; 11:cancers11030294. [PMID: 30832257 PMCID: PMC6468393 DOI: 10.3390/cancers11030294] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Pre-operative radiosurgery (SRS) preceding the resection of brain metastases promises to circumvent limitations of post-operative cavity SRS. It minimizes uncertainties regarding delineation and safety margins and could reduce dose exposure of the healthy brain (HB). METHODS We performed a systematic treatment plan comparison on 24 patients who received post-operative radiosurgery of the resection cavity at our institution. Comparative treatment plans were calculated for hypofractionated stereotactic radiotherapy (7 × 5 Gray (Gy)) in a hypothetical pre-operative (pre-op) and two post-operative scenarios, either with (extended field, post-op-E) or without the surgical tract (involved field, post-op-I). Detailed volumetric comparison of the resulting target volumes was performed, as well as dosimetric comparison focusing on targets and the HB. RESULTS The resection cavity was significantly smaller and different in morphology from the pre-operative lesion, yielding a low Dice Similarity Coefficient (DSC) of 53% (p = 0.019). Post-op-I and post-op-E targets showed high similarity (DSC = 93%), and including the surgical tract moderately enlarged resulting median target size (18.58 ccm vs. 22.89 ccm, p < 0.001). Dosimetric analysis favored the pre-operative treatment setting since it significantly decreased relevant dose exposure of the HB (Median volume receiving 28 Gy: 6.79 vs. 10.79 for pre-op vs. post-op-E, p < 0.001). Dosimetrically, pre-operative SRS is a promising alternative to post-operative cavity irradiation that could furthermore offer practical benefits regarding delineation and treatment planning. Comparative trials are required to evaluate potential clinical advantages of this approach.
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