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Al-Rubaiey S, Senger C, Bukatz J, Krantchev K, Janas A, Eitner C, Nieminen-Kelhä M, Brandenburg S, Zips D, Vajkoczy P, Acker G. Determinants of cerebral radionecrosis in animal models: A systematic review. Radiother Oncol 2024; 199:110444. [PMID: 39067705 DOI: 10.1016/j.radonc.2024.110444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 06/13/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Radionecrosis is a common complication in radiation oncology, while mechanisms and risk factors have yet to be fully explored. We therefore conducted a systematic review to understand the pathogenesis and identify factors that significantly affect the development. METHODS We performed a systematic literature search based on the PRISMA guidelines using PubMed, Ovid, and Web of Science databases. The complete search strategy can be found as a preregistered protocol on PROSPERO (CRD42023361662). RESULTS We included 83 studies, most involving healthy animals (n = 72, 86.75 %). High doses of hemispherical irradiation of 30 Gy in rats and 50 Gy in mice led repeatedly to radionecrosis among different studies and set-ups. Higher dose and larger irradiated volume were associated with earlier onset. Fractionated schedules showed limited effectiveness in the prevention of radionecrosis. Distinct anatomical brain structures respond to irradiation in various ways. White matter appears to be more vulnerable than gray matter. Younger age, more evolved animal species, and genetic background were also significant factors, whereas sex was irrelevant. Only 13.25 % of the studies were performed on primary brain tumor bearing animals, no studies on brain metastases are currently available. CONCLUSION This systematic review identified various factors that significantly affect the induction of radionecrosis. The current state of research neglects the utilization of animal models of brain tumors, even though patients with brain malignancies constitute the largest group receiving brain irradiation. This latter aspect should be primarily addressed when developing an experimental radionecrosis model for translational implementation.
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Affiliation(s)
- Sanaria Al-Rubaiey
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany; Department of Radiation Oncology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1 13353, Berlin, Germany.
| | - Carolin Senger
- Department of Radiation Oncology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1 13353, Berlin, Germany.
| | - Jan Bukatz
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany; Department of Radiation Oncology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1 13353, Berlin, Germany.
| | - Kiril Krantchev
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany.
| | - Anastasia Janas
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany; Berlin Institute of Health at Charité, Universitätsmedizin Berlin, Charitéplatz 1 10117, Berlin, Germany.
| | - Chiara Eitner
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany.
| | - Melina Nieminen-Kelhä
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany.
| | - Susan Brandenburg
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany.
| | - Daniel Zips
- Department of Radiation Oncology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1 13353, Berlin, Germany.
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany.
| | - Güliz Acker
- Department of Neurosurgery, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1 10117, Berlin, Germany; Berlin Institute of Health at Charité, Universitätsmedizin Berlin, Charitéplatz 1 10117, Berlin, Germany; Department of Radiation Oncology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1 13353, Berlin, Germany.
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Mukwada G, Chamunyonga C, Rowshanfarzad P, Gill S, Ebert MA. Insights into the dosimetric and geometric characteristics of stereotactic radiosurgery for multiple brain metastases: A systematic review. PLoS One 2024; 19:e0307088. [PMID: 39121064 PMCID: PMC11315342 DOI: 10.1371/journal.pone.0307088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/30/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND GammaKnife (GK) and CyberKnife (CK) have been the mainstay stereotactic radiosurgery (SRS) solution for multiple brain metastases (MBM) for several years. Recent technological advancement has seen an increase in single-isocentre C-arm linac-based SRS. This systematic review focuses on dosimetric and geometric insights into contemporary MBM SRS and thereby establish if linac-based SRS has matured to match the mainstay SRS delivery systems. METHODS The PubMed, Web of Science and Scopus databases were interrogated which yielded 891 relevant articles that narrowed to 20 articles after removing duplicates and applying the inclusion and exclusion criteria. Primary studies which reported the use of SRS for treatment of MBM SRS and reported the technical aspects including dosimetry were included. The review was limited to English language publications from January 2015 to August 2023. Only full-length papers were included in the final analysis. Opinion papers, commentary pieces, letters to the editor, abstracts, conference proceedings and editorials were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The reporting of conformity indices (CI) and gradient indices, V12Gy, monitor units and the impact of translational and rotational shifts were extracted and analysed. RESULTS The single-isocentre technique for MBM dominated recent SRS studies and the most studied delivery platforms were Varian. The C-arm linac-based SRS plan quality and normal brain tissue sparing was comparable to GK and CK and in some cases better. The most used nominal beam energy was 6FFF, and optimised couch and collimator angles could reduce mean normal brain dose by 11.3%. Reduction in volume of the healthy brain receiving a certain dose was dependent on the number and size of the metastases and the relative geometric location. GK and CK required 4.5-8.4 times treatment time compared with linac-based SRS. Rotational shifts caused larger changes in CI in C-arm linac-based single-isocentre SRS. CONCLUSION C-arm linac-based SRS produced comparable MBM plan quality and the delivery is notably shorter compared to GK and CK SRS.
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Affiliation(s)
- Godfrey Mukwada
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Western Australia, Australia
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
| | - Crispen Chamunyonga
- School of Clinical Sciences, Discipline of Radiation Therapy, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
- Centre for Advanced Technologies in Cancer Research (CATCR), Perth, Western Australia, Australia
| | - Suki Gill
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Western Australia, Australia
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
| | - Martin A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Western Australia, Australia
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
- Centre for Advanced Technologies in Cancer Research (CATCR), Perth, Western Australia, Australia
- School of Medicine and Population Health, University of Wisconsin, Madison, Wisconsin, United States of America
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Patwe PT, Deshpande S, Chaudhari S, Mahajan GR. Stereotactic radiosurgery in India: A nationwide survey of technology and quality assurance practices. J Cancer Res Ther 2024; 20:1013-1019. [PMID: 38261442 DOI: 10.4103/jcrt.jcrt_459_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/12/2023] [Indexed: 01/25/2024]
Abstract
PURPOSE India is rapidly adopting advanced treatments like Stereotactic Radiosurgery (SRS). However, there is a paucity of data on SRS practice. The aim of study is to assess the current status of technology and practices of machine quality assurance (QA) and patient specific quality assurance for SRS in India. MATERIALS AND METHODS A survey questionnaire was designed using Google Forms and sent to chief/senior medical physicists across 220 radiotherapy centers in India on July 15, 2022. It contained questions on infrastructure availability, treatment planning, and QA. RESULTS SRS was found to be extensively used for the treatment of brain metastases (99.3%), followed by meningioma (50.3%), acoustic neuroma (45.5%), and pituitary tumours (33.1%). The most commonly used photon energy and treatment technique were 6MV FFF and VMAT, respectively. A prescription isodose line ranging from 70% to 100% was selected by linac users. Most linac institutes verify pretreatment doses. There was a lack of uniformity in the analysis metrics such as Low Dose Threshold, Dose Difference, and Distance to Agreement. A survey revealed that the variety of SRS QA programs being followed at Indian radiotherapy centers. CONCLUSION This is the first study to report the physics practice of SRS in India. The survey shows a need to carry out a postal dose audit for small static photon fields in India.
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Affiliation(s)
- Parimal T Patwe
- School of Physical Sciences, Swami Ramanand Tirth Marathwada University, Hadgaon, Nanded, Maharashtra, India
- Department of Radiation Oncology, National Cancer Institute, Nagpur, Maharashtra, India
| | - Sudesh Deshpande
- Department of Radiation Oncology, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Suresh Chaudhari
- Department of Radiation Oncology, American Oncology Institute, Hydrabad, Telangana, India
| | - Gajanan R Mahajan
- Department of Physics, Shri Datta Arts, Commerce and Science College, Hadgaon, Nanded, Maharashtra, India
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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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Amidon RF, Livingston K, Kleefisch CJ, Martens M, Straza M, Puckett L, Schultz CJ, Mueller WM, Connelly JM, Noid G, Morris K, Bovi JA. Cystic Brain Metastasis Outcomes After Gamma Knife Radiation Therapy. Adv Radiat Oncol 2024; 9:101304. [PMID: 38260234 PMCID: PMC10801666 DOI: 10.1016/j.adro.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/13/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose The response of cystic brain metastases (BMets) to radiation therapy is poorly understood, with conflicting results regarding local control, overall survival, and treatment-related toxicity. This study aims to examine the role of Gamma Knife (GK) in managing cystic BMets. Methods and Materials Volumetric analysis was conducted to measure tumor and edema volume at the time of GK and follow-up magnetic resonance imaging studies. Survival was described using the Kaplan-Meier method, and the cumulative incidence of progression was described using the Aalen-Johansen estimator. We evaluated the association of 4 variables with survival using Cox regression analysis. Results Between 2016 and 2021, 54 patients with 83 cystic BMets were treated with GK at our institution. Lung cancer was the most common pathology (51.9%), followed by breast cancer (13.0%). The mean target volume was 2.7 cm3 (range, 0.1-39.0 cm3), and the mean edema volume was 13.9 cm3 (range, 0-165.5 cm3). The median prescription dose of single-fraction and fractionated GK was 20 Gy (range, 14-27.5 Gy). With a median follow-up of 8.9 months, the median survival time (MST) was 11.1 months, and the 1-year local control rate was 75.9%. Gamma Knife was associated with decreased tumor and edema volumes over time, although 68.5% of patients required steroids after GK. Patients whose tumors grew beyond baseline after GK received significantly more whole-brain radiation therapy (WBRT) before GK than those whose tumors declined after GK. Higher age at diagnosis of BMets and pre-GK systemic therapy were associated with worse survival, with an MST of 7.8 months in patients who received it compared with 23.3 months in those who did not. Conclusions Pre-GK WBRT may select for BMets with increased radioresistance. This study highlights the ability of GK to control cystic BMets with the cost of high posttreatment steroid use.
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Affiliation(s)
- Ryan F Amidon
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | - Michael Martens
- Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Straza
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lindsay Puckett
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Wade M Mueller
- Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - George Noid
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kirk Morris
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joseph A Bovi
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Mukwada G, Skorska M, Rowshanfarzad P, Ebert MA. Comparison of the accuracy of Monte Carlo and Ray Tracing dose calculation algorithms for multiple target brain treatments on CyberKnife. Phys Eng Sci Med 2023; 46:1477-1487. [PMID: 37552365 DOI: 10.1007/s13246-023-01312-w] [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: 01/22/2023] [Accepted: 07/26/2023] [Indexed: 08/09/2023]
Abstract
Single plan multiple brain targets (MBT) stereotactic radiosurgery dose difference between Monte Carlo (MC) and Ray Tracing (RT) algorithms has not been studied. A retrospective study and dose measurements were performed to access factors influencing dose differences. Fifty-three RT treatment plans with a total of 209 brain metastases were extracted from Precision Treatment Planning System (TPS). These plans were generated using fixed cones and were delivered using the CyberKnife M6 system. The same treatment plans were recalculated using MC algorithm and keeping the beam parameters unchanged. MC calculated plan parameters were extracted and dose differences were normalised to MC calculated dose. Correlations were investigated. RT and MC calculated off-centre-ratio (OCR) and tissue-phantom-ratio (TPRs) were exported from the TPS and compared with measured. Plans with 5 gross tumour volumes (GTVs) were created on a phantom and dose measured using a CC04 ionisation chamber and microdiamond detector for comparison with calculated doses. Calculated and measured TPR agreed within ± 1% beyond depth of maximum dose. The OCR showed differences up to 4.3% in the penumbra and out-of-field (OOF) regions. Largest RT and MC calculated GTV mean dose difference was - 5.7%. An increase in the number of GTVs and reduction in the geometric separation of metastases were associated with increased differences between RT and MC calculated doses. In conclusion, calculated dose disagreement in MBT depends on the number of GTVs per plan, number of GTVs within a certain separation distance and plan complexity. MC dose calculation is recommended for complex CyberKnife SRS of MBT.
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Affiliation(s)
- Godfrey Mukwada
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, WA, Australia.
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, Australia.
| | - Malgorzata Skorska
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, WA, Australia
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, Australia
| | - Martin A Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, WA, Australia
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, Australia
- 5D Clinics, Claremont, WA, Australia
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Rozati H, Chen J, Williams M. Overall survival following stereotactic radiosurgery for ten or more brain metastases: a systematic review and meta-analysis. BMC Cancer 2023; 23:1004. [PMID: 37858075 PMCID: PMC10585836 DOI: 10.1186/s12885-023-11452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Brain metastases are the most common intracranial tumours. Variation exists in the use of stereotactic radiosurgery for patients with 10 or more brain metastases. Concerns include an increasing number of brain metastases being associated with poor survival, the lack of prospective, randomised data and an increased risk of toxicity. METHODS We performed a systematic review and meta-analysis to assess overall survival of patients with ten or more brain metastases treated with stereotactic radiosurgery as primary therapy. The search strings were applied to MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). Log hazard ratios and standard errors were estimated from each included study. A random-effects meta-analysis using the DerSimonian and Laird method was applied using the derived log hazard ratios and standard errors on studies which included a control group. RESULTS 15 studies were included for systematic review. 12 studies were used for pooled analysis for overall survival at set time points, with a predicted 12 month survival of 20-40%. The random-effects meta-analysis in five studies of overall survival comparing ten or greater metastases against control showed statistically worse overall survival in the 10 + metastases group (1.10, 95% confidence interval 1.03-1.18, p-value = < 0.01, I2 = 6%). A funnel plot showed no evidence of bias. There was insufficient information for a meta-analysis of toxicity. DISCUSSION Overall survival outcomes of patients with ten or more brain metastases treated with SRS is acceptable and should not be a deterrent for its use. There is a lack of prospective data and insufficient real-world data to draw conclusions on toxicity. PROSPERO ID CRD42021246115.
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Affiliation(s)
- Hamoun Rozati
- London Gamma Knife Centre, Platinum Medical Centre, Wellington Hospital, Lodge Road, London, UK
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jiarong Chen
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, UK
- Clinical Experimental Center, Jiangmen Key Laboratory of Clinical Biobanks and Translational Research, Jiangmen Central Hospital, Jiangmen, 529030, China
| | - Matt Williams
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, UK.
- Department of Radiotherapy, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Church C, Parsons D, Syme A. Region-of-interest intra-arc MV imaging to facilitate sub-mm positional accuracy with minimal imaging dose during treatment deliveries of small cranial lesions. J Appl Clin Med Phys 2022; 23:e13769. [PMID: 36052995 PMCID: PMC9680576 DOI: 10.1002/acm2.13769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/15/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To automate the generation of region‐of‐interest (ROI) apertures for use with megavoltage imaging for online positional corrections during cranial stereotactic radiosurgery. Materials and methods Digitally reconstructed radiographs (DRRs) were created for a 3D‐printed skull phantom at 5 degree gantry angle increments for a three‐arc beam arrangement. At each angle, 3000 random rectangular apertures were generated, and 100 shifts on a grid were applied to the anatomy within the frame. For all shifts, the mutual information (MI) between the shifted and unshifted DRR was calculated to derive an average MI gradient. The top 10% of apertures that minimized registration errors were overlaid and discretely thresholded to generate imaging plans. Imaging was acquired with the skull while implementing simulated patient motion on a linac. Control point‐specific couch motions were derived to align the skull to its planned positioning. Results Apertures with a range of repositioning errors less than 0.1 mm possessed a 42% larger average MI gradient when compared with apertures with a range greater than 1 mm. Dose calculations with Monte Carlo exhibited an 84% reduction in the dose received by 50% of the skull with the 50% thresholded plan when compared to a constant 22 × 22 cm2 imaging plan. For all different imaging plans (with and without motion), the calculated median 3D‐errors with respect to the tracking of a metal‐BB fiducial positioned at isocenter in the skull were sub‐mm except for the 80% thresholded plan. Conclusions Sub‐mm positional errors are achievable with couch motions derived from control point–specific ROI imaging. Smaller apertures that conform to an anatomical ROI can be utilized to minimize the imaging dose incurred at the expense of larger errors.
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Affiliation(s)
- Cody Church
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alasdair Syme
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
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Mathis NJ, Wijetunga NA, Imber BS, Pike LRG, Yang JT. Recent Advances and Applications of Radiation Therapy for Brain Metastases. Curr Oncol Rep 2022; 24:335-342. [PMID: 35133614 DOI: 10.1007/s11912-022-01209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Radiation therapy (RT) is a mainstay of treatment for brain metastases from solid tumors. Treatment of these patients is complex and should focus on minimizing symptoms, preserving functional status, and prolonging survival. RECENT FINDINGS Whole-brain radiotherapy (WBRT) can lead to toxicity, and while it does reduce recurrence in the CNS, this has not been shown to provide a survival benefit. Recent advances focus on reducing the toxicity of WBRT or using more targeted radiation therapy. New paradigms including the use of proton RT for leptomeningeal metastases (LM) and stereotactic radiosurgery (SRS) before craniotomy hold promise in improving treatment efficacy and reducing toxicity. Omission or replacement of WBRT is often safe and the use of SRS is expanding to include patients with more lesions and preoperative RT. Proton RT holds promise for LM. Progress is being made in improving patient-centered outcomes and reducing toxicity for patients with brain metastases.
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Affiliation(s)
- Noah J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - N Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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Agazaryan N, Tenn S, Lee C, Steinberg M, Hegde J, Chin R, Pouratian N, Yang I, Kim W, Kaprealian T. Simultaneous radiosurgery for multiple brain metastases: technical overview of the UCLA experience. Radiat Oncol 2021; 16:221. [PMID: 34789300 PMCID: PMC8597274 DOI: 10.1186/s13014-021-01944-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/01/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE/OBJECTIVE(S) To communicate our institutional experience with single isocenter radiosurgery treatments for multiple brain metastases, including challenges with determining planning target volume (PTV) margins and resulting consequences, image-guidance translational and rotational tolerances, intra-fraction patient motion, and prescription considerations with larger PTV margins. MATERIALS/METHODS Eight patient treatments with 51 targets were planned with various margins using Elements Multiple Brain Mets SRS treatment planning software (Brainlab, Munich, Germany). Forty-eight plans with 0 mm, 1 mm and 2 mm margins were created, including plans with variable margins, where targets more than 6 cm away from the isocenter were planned with larger margins. The dosimetric impact of the margins were analyzed with V5Gy, V8Gy, V10Gy, V12Gy values. Additionally, 12 patient motion data were analyzed to determine both the impact of the repositioning threshold and the distributions of the patient translational and rotational movements. RESULTS The V5Gy, V8Gy, V10Gy, V12Gy volumes approximately doubled when margins change from 0 to 1 mm and tripled when change from 0 to 2 mm. With variable margins, the aggregated results are similar to results from plans using the lower of two margins, since only 12.2% of the targets were more than 6 cm away from the isocenter. With 0.5 mm re-positioning threshold, 57.4% of the time the patients are repositioned. Reducing the threshold to 0.25 mm results in 91.7% repositioning rate, due to limitations of the fusion algorithm and actual patient motion. The 90th percentile of translational movements in all directions is 0.7 mm, while the 90th percentile of rotational movements in all directions is 0.6 degrees. Median translations and rotations are 0.2 mm and 0.2 degrees, respectively. CONCLUSIONS Based on the data presented, we have switched our modus operandi from 2 to 1 mm PTV margins, with an eventual goal of using 0.5 and 1.0 mm variable margins when an automated margin assignment method becomes available. The 0.5 mm and 0.5 degrees repositioning thresholds are clinically appropriate with small residual patient movements.
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Affiliation(s)
- Nzhde Agazaryan
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Steve Tenn
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Chul Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michael Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - John Hegde
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert Chin
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Isaac Yang
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Won Kim
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tania Kaprealian
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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11
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Bowden GN, Kim JO, Faramand A, Fallon K, Flickinger J, Lunsford LD. Clinical dose profile of Gamma Knife stereotactic radiosurgery for extensive brain metastases. J Neurosurg 2021; 134:1430-1434. [PMID: 32384280 DOI: 10.3171/2020.3.jns193369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of Gamma Knife stereotactic radiosurgery (GKSRS) for the treatment of extensive intracranial metastases has been expanding due to its superior dosimetry and efficacy. However, there remains a dearth of data regarding the dose parameters in actual clinical scenarios. The authors endeavored to calculate the radiation dose to the brain when treating ≥ 15 brain metastases with GKSRS. METHODS This retrospective analysis reviewed dosage characteristics for patients requiring single-session GKSRS for the treatment of ≥ 15 brain metastases. Forty-two patients met the inclusion criteria between 2008 and 2017. The median number of tumors at the initial GKSRS procedure was 20 (range 15-39 tumors), accounting for 865 tumors in this study. The median aggregate tumor volume was 3.1 cm3 (range 0.13-13.26 cm3), and the median marginal dose was 16 Gy (range 14-19 Gy). RESULTS The median of the mean brain dose was 2.58 Gy (range 0.95-3.67 Gy), and 79% of patients had a dose < 3 Gy. The 12-Gy dose volume was a median of 12.45 cm3, which was equivalent to 0.9% of the brain volume. The median percentages of brain receiving 5 Gy and 3 Gy were 6.7% and 20.4%, respectively. There was no correlation between the number of metastases and the mean dose to the brain (p = 0.8). A greater tumor volume was significantly associated with an increased mean brain dose (p < 0.001). The median of the mean dose to the bilateral hippocampi was 2.3 Gy. Sixteen patients had supplementary GKSRS, resulting in an additional mean dose of 1.4 Gy (range 0.2-3.8 Gy) to the brain. CONCLUSIONS GKSRS is a viable means of managing extensive brain metastases. This procedure provides a relatively low dose of radiation to the brain, especially when compared with traditional whole-brain radiation protocols.
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Affiliation(s)
- Gregory Neil Bowden
- 1Department of Neurological Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jong Oh Kim
- Departments of2Radiation Oncology (Medical Physics) and
| | - Andrew Faramand
- 3Neurological Surgery and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - Kevin Fallon
- 4Department of Radiation Oncology (Medical Physics), Medical University of South Carolina, Charleston, South Carolina
| | | | - L Dade Lunsford
- 3Neurological Surgery and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
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12
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Parikh NR, Kundu P, Levin-Epstein R, Chang EM, Agazaryan N, Hegde JV, Steinberg ML, Tenn SE, Kaprealian TB. Time-Driven Activity-Based Costing Comparison of Stereotactic Radiosurgery to Multiple Brain Lesions Using Single-Isocenter Versus Multiple-Isocenter Technique. Int J Radiat Oncol Biol Phys 2020; 108:999-1007. [PMID: 32603774 DOI: 10.1016/j.ijrobp.2020.06.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/30/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) historically has been used to treat multiple brain lesions using a multiple-isocenter technique-frequently associated with significant complexity in treatment planning and long treatment times. Recently, given innovations in planning algorithms, patients with multiple brain lesions may now be treated with a single-isocenter technique using fewer total arcs and less time spent during image guidance (though with stricter image guided radiation therapy tolerances). This study used time-driven activity-based costing to determine the difference in cost to a provider for delivering SRS to multiple brain lesions using single-isocenter versus multiple-isocenter techniques. METHODS AND MATERIALS Process maps, consisting of discrete steps, were created for each phase of the SRS care cycle and were based on interviews with department personnel. Actual treatment times (including image guidance) were extracted from treatment record and verify software. Additional sources of data to determine costs included salary/benefit data of personnel and average list price/maintenance costs for equipment. RESULTS Data were collected for 22 patients who underwent single-isocenter SRS (mean lesions treated, 5.2; mean treatment time, 30.2 minutes) and 51 patients who underwent multiple-isocenter SRS (mean lesions treated, 4.4; mean treatment time, 75.2 minutes). Treatment time for multiple-isocenter SRS varied substantially with increasing number of lesions (11.8 minutes/lesion; P < .001), but to a much lesser degree in single-isocenter SRS (1.8 minutes/lesion; P = .029). The resulting cost savings from single-isocenter SRS based on number of lesions treated ranged from $296 to $3878 for 2 to 10 lesions treated. The 2-mm planning treatment volume margin used with single-isocenter SRS resulted in a mean 43% increase of total volume treated compared with a 1-mm planning treatment volume expansion. CONCLUSIONS In a comparison of time-driven activity-based costing assessment of single-isocenter versus multiple-isocenter SRS for multiple brain lesions, single-isocenter SRS appears to save time and resources for as few as 2 lesions, with incremental benefits for additional lesions treated.
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Affiliation(s)
- Neil R Parikh
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Palak Kundu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Eric M Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Nzhde Agazaryan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - John V Hegde
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Stephen E Tenn
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Tania B Kaprealian
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
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13
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Zhang M, Fan Q, Lei Y, Thapa B, Padula G. Assessment of an Elekta Versa HD linear accelerator for stereotactic radiosurgery with circular cone collimators. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2020; 28:71-82. [PMID: 31904001 DOI: 10.3233/xst-190580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Versa HD linear accelerators (linacs) are used for stereotactic radiosurgery treatment. However, the mechanical accuracy of such systems remains a concern. OBJECTIVE The purpose of this study was to evaluate the accuracy of an Elekta Versa HD linac. METHODS We performed measurements with a ball bearing phantom to calculate the rotational isocenter radii of the linac's gantry, collimator, and table, and determine the relative locations of those isocenters. We evaluated the accuracy of the cone-beam computed tomography (CBCT) guidance with a film-embedding head phantom and circular cone-collimated radiation beams. We also performed dosimetric simulations to study the effects of the linac mechanical uncertainties on non-coplanar cone arc delivery. RESULTS The mechanical uncertainty of the linac gantry rotation was 0.78 mm in radius, whereas that of the collimator and the table was <0.1 mm and 0.33 mm, respectively. The axes of rotation of the collimator and the table were coinciding with and 0.13 mm away from the gantry isocenter, respectively. Experiments with test plans demonstrated the limited dosimetric consequences on the circular arc delivery given the aforementioned mechanical uncertainties. End-to-end measurements determined that the uncertainty of the CBCT guidance was≤1 mm in each direction with respect to the reference CT image. CONCLUSIONS In arc delivery, the mechanical uncertainties associated with the gantry and the table do not require remarkable increases in geometric margins. If large enough, the residual setup errors following CBCT guidance will dominate the overall dosimetric consequence. Therefore, the Versa HD linac is a valid system for stereotactic radiosurgery using non-coplanar arc delivery.
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Affiliation(s)
- Mutian Zhang
- Radiation Therapy, Summa Health Cancer Institute, Akron, Ohio, USA
| | - Qiyong Fan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yu Lei
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bishnu Thapa
- Radiation Therapy, Summa Health Cancer Institute, Akron, Ohio, USA
| | - Gilbert Padula
- Radiation Therapy, Summa Health Cancer Institute, Akron, Ohio, USA
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14
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Ahn KH, Yenice KM, Koshy M, Slavin KV, Aydogan B. Frame-based radiosurgery of multiple metastases using single-isocenter volumetric modulated arc therapy technique. J Appl Clin Med Phys 2019; 20:21-28. [PMID: 31328368 PMCID: PMC6698758 DOI: 10.1002/acm2.12672] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/15/2019] [Accepted: 06/15/2019] [Indexed: 11/11/2022] Open
Abstract
Single‐isocenter volumetric modulated arc therapy (VMAT) technique can provide stereotactic radiosurgery (SRS) treatment with improved delivery efficiency for treating multiple metastases. Nevertheless, planning is time consuming and verification of frame‐based SRS setup, especially at noncoplanar angles, can be challenging. We report on a single‐isocenter VMAT technique with a special focus on improving treatment workflow and delivery verification to exploit the minimized patient motion of the frame‐based SRS. We developed protocols for preplanning and verification for VMAT and evaluated them for ten patient cases. Preplans based on MRI were used to generate comparable treatment plans using CT taken on the day of treatment after frame placement. Target positioning accuracy was evaluated by stereoscopic in‐room kV imaging. Dosimetric accuracy of the noncoplanar plan delivery was validated using measurement‐guided 3D dose reconstruction as well as film‐based end‐to‐end test with a Rando phantom. Average absolute differences of homogeneity indices, conformity indices, and V12Gy between MR preplans and CT‐based plans were within 5%. In‐room imaging positioning accuracy of 0.4 mm was verified to be independent of the distance to the isocenter. For treatment verification, average local and global passing rates of the 3D gamma (1 mm, 3%) were 86% and 99%, respectively. D99 values were matched within 5% for individual target structures (>0.5 cc). Additional film analysis confirmed dosimetric accuracy for small targets that had large verification errors in the 3D dose reconstruction. Our results suggest that the advantages of frame‐based SRS and noncoplanar single‐isocenter VMAT technique can be combined for efficient and accurate treatment of patients with multiple metastases.
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Affiliation(s)
- Kang-Hyun Ahn
- Department of Radiation Oncology, University of Illinois, Chicago, IL, USA.,Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Kamil M Yenice
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Matthew Koshy
- Department of Radiation Oncology, University of Illinois, Chicago, IL, USA.,Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | | | - Bulent Aydogan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
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