Fractionated stereotactic radiotherapy: a short review

Comparison of Staged Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy in Patients with Brain Metastases > 2 cm without Prior Whole Brain Radiotherapy: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare fractionated stereotactic radiotherapy (FSRT) with staged stereotactic radiosurgery (SSRS) in patients with brain metastases >2 cm without prior whole brain radiotherapy.

METHODS

In this systematic review and meta-analysis, PubMed, Scopus, Web of Science, Embase, and Cochrane were searched to include studies that evaluated FSRT and/or SSRS for brain metastases >2 cm or 4 cm3 in adult patients with a known primary malignancy and no prior history of whole brain radiotherapy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and an indirect random-effect meta-analyses was conducted to compare treatment outcomes between the two modalities.

RESULTS

A total of 10 studies were included, comprising 612 (778 metastases) and 250 patients (265 metastases) in the SSRS and FSRT groups, respectively. The SSRS group had significantly older patients (66.6 ± 17.51 years vs. 62.37 ± 37.89 years; P = 0.029) with lower rate of control of primary disease (11.59% vs. 78.7%, P < 0.00001), and more patients with Karnofsky performance status ≥70 at baseline (92.81% vs. 88.56%; P = 0.045). FSRT was associated with a statistically nonsignificant but clinically important lower 12-month overall survival (44.75% [95% confidence interval [CI]: 30.48%-59.95%] vs. 53.25% [95%CI: 45.15%-61.19%], P = 0.1615) and higher rate of salvage radiotherapy (18.18% [95%CI: 8.75%-34%] vs. 12.27% [95%CI: 5.98%-23.53%], P = 0.0841). Both groups had comparable rates of local tumor control, mortality, tumor progression, recurrence, neurological death, and 6-month overall survival.

CONCLUSIONS

SSRS and FSRT were found to be comparable for treating brain metastases >2 cm not previously irradiated. Given the paucity of such studies, trials directly comparing the two treatment strategies are warranted to support these findings.

Incidental Meningiomas: Potential Predictors of Growth and Current State of Management

The rise in availability of neuroimaging has led to an increase in incidentally discovered meningiomas. These tumors are typically asymptomatic and tend to display slow growth. Treatment options include observation with serial monitoring, radiation, and surgery. Although optimal management is unclear, clinicians recommend a conservative approach, which preserves quality of life and limits unnecessary intervention. Several risk factors have been investigated for their potential utility in the development of prognostic models for risk assessment. Herein, the authors review the current literature on incidental meningiomas, focusing their discussion on potential predictive factors for tumor growth and appropriate management practices.

The Promise of Magnetic Resonance Imaging in Radiation Oncology Practice in the Management of Brain, Prostate, and GI Malignancies

Magnetic resonance imaging (MRI) has a key role to play at multiple steps of the radiotherapy (RT) treatment planning and delivery process. Development of high-precision RT techniques such as intensity-modulated RT, stereotactic ablative RT, and particle beam therapy has enabled oncologists to escalate RT dose to the target while restricting doses to organs at risk (OAR). MRI plays a critical role in target volume delineation in various disease sites, thus ensuring that these high-precision techniques can be safely implemented. Accurate identification of gross disease has also enabled selective dose escalation as a means to widen the therapeutic index. Morphological and functional MRI sequences have also facilitated an understanding of temporal changes in target volumes and OAR during a course of RT, allowing for midtreatment volumetric and biological adaptation. The latest advancement in linear accelerator technology has led to the incorporation of an MRI scanner in the treatment unit. MRI-guided RT provides the opportunity for MRI-only workflow along with online adaptation for either target or OAR or both. MRI plays a key role in post-treatment response evaluation and is an important tool for guiding decision making. In this review, we briefly discuss the RT-related applications of MRI in the management of brain, prostate, and GI malignancies.

Practice Patterns of Stereotactic Radiotherapy in Pediatrics: Results From an International Pediatric Research Consortium

PURPOSE/OBJECTIVES

There is little consensus regarding the application of stereotactic radiotherapy (SRT) in pediatrics. We evaluated patterns of pediatric SRT practice through an international research consortium.

MATERIALS AND METHODS

Eight international institutions with pediatric expertise completed a 124-item survey evaluating patterns of SRT use for patients 21 years old and younger. Frequencies of SRT use and median margins applied with and without SRT were evaluated.

RESULTS

Across institutions, 75% reported utilizing SRT in pediatrics. SRT was used in 22% of brain, 18% of spine, 16% of other bone, 16% of head and neck, and <1% of abdomen/pelvis, lung, and liver cases across sites. Of the hypofractionated SRT cases, 42% were delivered with definitive intent. Median gross tumor volume to planning target volume margins for SRT versus non-SRT plans were 0.2 versus 1.4 cm for brain, 0.3 versus 1.5 cm for spine/other bone, 0.3 versus 2.0 cm for abdomen/pelvis, 0.7 versus 1.5 cm for head and neck, 0.5 versus 1.7 cm for lung, and 0.5 versus 2.0 cm for liver sites.

CONCLUSIONS

SRT is commonly utilized in pediatrics across a range of treatment sites. Margins used for SRT were substantially smaller than for non-SRT planning, highlighting the utility of this approach in reducing treatment volumes.

The potential for an enhanced role for MRI in radiation-therapy treatment planning

The exquisite soft-tissue contrast of magnetic resonance imaging (MRI) has meant that the technique is having an increasing role in contouring the gross tumor volume (GTV) and organs at risk (OAR) in radiation therapy treatment planning systems (TPS). MRI-planning scans from diagnostic MRI scanners are currently incorporated into the planning process by being registered to CT data. The soft-tissue data from the MRI provides target outline guidance and the CT provides a solid geometric and electron density map for accurate dose calculation on the TPS computer. There is increasing interest in MRI machine placement in radiotherapy clinics as an adjunct to CT simulators. Most vendors now offer 70 cm bores with flat couch inserts and specialised RF coil designs. We would refer to these devices as MR-simulators. There is also research into the future application of MR-simulators independent of CT and as in-room image-guidance devices. It is within the background of this increased interest in the utility of MRI in radiotherapy treatment planning that this paper is couched. The paper outlines publications that deal with standard MRI sequences used in current clinical practice. It then discusses the potential for using processed functional diffusion maps (fDM) derived from diffusion weighted image sequences in tracking tumor activity and tumor recurrence. Next, this paper reviews publications that describe the use of MRI in patient-management applications that may, in turn, be relevant to radiotherapy treatment planning. The review briefly discusses the concepts behind functional techniques such as dynamic contrast enhanced (DCE), diffusion-weighted (DW) MRI sequences and magnetic resonance spectroscopic imaging (MRSI). Significant applications of MR are discussed in terms of the following treatment sites: brain, head and neck, breast, lung, prostate and cervix. While not yet routine, the use of apparent diffusion coefficient (ADC) map analysis indicates an exciting future application for functional MRI. Although DW-MRI has not yet been routinely used in boost adaptive techniques, it is being assessed in cohort studies for sub-volume boosting in prostate tumors.

Focal radiation therapy of brain metastases after complete surgical resection

Brain metastases are a frequent occurrence in cancer patients and result in significant morbidity and mortality. The three main treatments for brain metastases include surgery, radiation, and/or chemotherapy, alone or in combination. After resection alone, local recurrence rates are high. Whole brain radiation therapy can decrease the probability of recurrence; however, this has some disadvantages. Focal radiation therapy (FRT) may provide many of the same benefits without some of these disadvantages. In this study, we retrospectively analyzed patients with single brain metastases treated with FRT after surgery. Doses ranged from 14 Gy as single dose stereotactic radiosurgery (SRS) to 54 Gy in 27 2-Gy fractions as conformal fractionated radiotherapy. Four of the seven patients had a same-site recurrence, with an average time to recurrence of 115.5 d. Median dose in the patients that had same-site recurrence was 42 Gy. One of these patients is currently living. Two patients did not have recurrence, and one patient had a recurrence at a different site within the brain. The low rate of out-of-field recurrences during the patients life indicates focal radiation may be a reasonable therapeutic alternative. Given the number of patients with same-site recurrences, wide field margins around the tumor volume or higher radiation doses than those typically used in palliative regimens may be useful in post-excisional FRT. Additionally, we found that a longer delay in the initiation of FRT after initial diagnosis may result in a decreased time to same-site recurrence. However, further studies are warranted given the small number of patients in this study.

Comparison of linac based fractionated stereotactic radiotherapy and tomotherapy treatment plans for skull-base tumors

BACKGROUND AND PURPOSE

To compare and evaluate helical tomotherapy and linac based fractionated stereotactic radiotherapy (FSRT) techniques in the treatment of skull-base tumors.

PATIENTS AND METHODS

Ten patients diagnosed with skull-base tumors, originally planned for optically guided FSRT to prescribed doses of 50.4-54 Gy were replanned for treatment with clinically deliverable helical tomotherapy. All original CT scans, MR-CT fusion defined target and normal structure contours, and PTV margins were used for helical tomotherapy planning. Linac based plans utilized one of the following FSRT planning techniques: non-coplanar or coplanar intensity modulated radiation therapy (IMRT), multiple non-coplanar conformal arcs, and non-coplanar conformal radiation therapy (CRT). These plans were used as the standard to which the subsequent tomotherapy plans were compared, using the following criteria: prescription isodose to target volume (PITV) ratios, an inhomogeneity index (II), equivalent uniform dose (EUD) for PTV volumes, mean normalized total doses (NTDmean) for critical structures, and size of 10, 20, and 30 Gy isodose volumes.

RESULTS

Use of both linac based FSRT techniques and helical tomotherapy generated highly conformal treatment plans. Tomotherapy plans, which are predominantly coplanar in nature, compared to non-coplanar linac based plans exhibited increased PITV ratios, variable change in II, similar EUD values, and generally comparable NTD(mean) values for organs at risk. When compared to non-coplanar field arrangements, deliverable (as opposed to idealized) tomotherapy plans also resulted in 13-540% increases in low dose isodose volumes. All criteria except for the II, which was generally improved with tomotherapy, were found to be similar when coplanar linac based plans were compared to helical tomotherapy plans.

CONCLUSIONS

Results show a distinct advantage in using non-coplanar beam arrangements for treatment of skull-base tumors. In the case where disease spreads far inferiorly, limiting the ability to use non-coplanar arrangements, helical tomotherapy can be used to generate a comparable treatment plan, with potentially superior homogeneity.

Treatment of Schwannomas with an Oncolytic Recombinant Herpes Simplex Virus in Murine Models of Neurofibromatosis Type 2

Gene therapy for schwannomas was evaluated in two mouse models of neurofibromatosis type 2 (NF2): (1) a transgenic model in which mice express a dominant mutant form of merlin and spontaneously develop schwannomas, and (2) a xenograft model in which human schwannoma tissue is implanted subcutaneously into immune- compromised mice. In both models, schwannoma volumes were monitored by magnetic resonance imaging (MRI) and showed strong gadolinium enhancement typical of these tumors in humans. Both types of tumor were positive for the Schwann cell marker S100, and highly infectable with herpes simplex virus (HSV) vectors. Schwannomas were injected with an oncolytic HSV-1 recombinant virus vector, G47Delta, which has deletions in genes for ribonucleotide reductase (ICP6), gamma34.5, and ICP47. In the NF2 transgenic model, schwannomas were reduced by more than half their original size by 10 days after infection. In the case of subcutaneous schwannoma xenografts, reduction in size after infection occurred more slowly, with a mean reduction of onethird by 42 days after treatment. Schwannomas injected with control vehicles continued to grow slowly over time in both schwannoma models. These studies demonstrate the ability of an oncolytic recombinant HSV vector to reduce the volume of schwannoma tumors in NF2 tumor models in mice and extend the possible therapeutic applications of oncolytic vectors for benign tumors to reduce mass while minimizing nerve damage.

Dynamic collimator optimization compared with fixed collimator angle in arc-based stereotactic radiotherapy: a dosimetric analysis

Object

The purpose of this study was to determine the effect of static and dynamic collimator optimization when using a micromultileaf collimator (mMLC) in dynamic-arc stereotactic radiosurgery (SRS) by evaluating the dose to healthy peritumoral tissue.

Methods

Thirty patients previously treated for intracranial lesions with the BrainLAB mMLC underwent retrospective replanning. Three collimator optimization strategies were compared for a simulated SRS treatment plan, as follows: Strategy 1, static collimation fixed at 90° throughout arcs; Strategy 2, static collimator settings optimized for each arc; and Strategy 3, dynamic collimator settings optimized every 10° throughout treatment arcs. Dose–volume histograms for a 0.7-cm shell of healthy peritumoral tissue were quantitatively compared.

Collimator optimization schemes (Strategies 2 and 3) significantly decreased the volume of peritumoral tissue that is irradiated when compared with static collimation at 90° (Strategy 1). The volume was reduced by 40.6% for Strategy 2 (95% confidence interval [CI] ± 11) and by 47.1% for Strategy 3 (95% CI ± 8.1) at the 95% isodose; by 28.4% for Strategy 2 (95% CI ± 4.9) and 39.1% for Strategy 3 (95% CI ± 6) at the 90% isodose; and by 18.2% for Strategy 2 (95% CI ± 8.1) and 25.4% for Strategy 3 (95% CI ± 7.1) at the 80% isodose. Serial collimator optimization throughout the treatment arcs (Strategy 3) reduced the mean volume of peritumoral tissue irradiated when compared with static collimator optimization (Strategy 2), by 16.1% (95% CI ± 1.5) at 95% isodose, by 11.7% (95% CI ± 1) at 90% isodose, and by 8.2% (95% CI ± 1.2) at 80% isodose regions. In specific cases, linear or polynomial functions were formulated to optimize collimator settings dynamically throughout treatment arcs.

Conclusions

Dynamic collimator optimization during arc-based SRS decreases the volume of healthy peritumoral tissue treated with high doses of radiation and appears to be an effective method of improving target conformality. This study is the first step toward determination of a smoothing function algorithm to allow for true dynamic collimation during SRS.

The impact of daily setup variations on head-and-neck intensity-modulated radiation therapy

PURPOSE

Intensity-modulated radiation therapy (IMRT) in the treatment of head-and-neck (H&N) cancer provides the opportunity to diminish normal tissue toxicity profiles and thereby enhance patient quality of life. However, highly conformal treatment techniques commonly establish steep dose gradients between tumor and avoidance structures. Daily setup variations can therefore significantly compromise the ultimate precision of idealized H&N IMRT delivery. This study provides a detailed analysis regarding the potential impact of daily setup variations on the overall integrity of H&N IMRT.

METHODS AND MATERIALS

A series of 10 patients with advanced H&N cancer were prospectively enrolled in a clinical trial to examine daily H&N radiation setup accuracy. These patients were treated with conventional shrinking field design using three-dimensional treatment planning techniques (not IMRT). Immobilization and alignment were performed using modern H&N practice techniques including conventional thermoplastic masking, baseplate fixation to the treatment couch, three-point laser alignment, and weekly portal film evaluation. After traditional laser alignment, setup accuracy was assessed daily for each patient by measuring 3 Cartesian and 3 angular deviations from the specified isocenter using a high-precision, optically guided patient localization system, which affords submillimeter setup accuracy. These positional errors were then applied to a distinct series of 10 H&N IMRT plans for detailed analysis regarding the impact of daily setup variation (without optical guidance) on the ultimate integrity of IMRT plans over a 30-day treatment course. Dose-volume histogram (DVH), equivalent uniform dose (EUD), mean total dose (mTd), and maximal total dose (MTD) for normal structures were analyzed for IMRT plans with and without incorporation of daily setup variation.

RESULTS

Using conventional H&N masking and laser alignment for daily positioning, the mean setup error in any single dimension averaged 3.33 mm. However, when all six degrees of freedom were accounted for, using the optically guided patient localization system, the mean composite vector offset was 6.97 mm with a standard deviation of 3.63 mm. Superimposition of mean offset vectors on idealized H&N IMRT treatment plans enabled evaluation of resultant shifts in DVH, EUD, mTd, and MTD calculations. Partial geographic tumor miss (GTV underdosing) and normal tissue overdosing was common when these mean positional offsets were incorporated. The decrease in EUD for defined tumor volumes ranged up to 21% when the largest offset histories were applied, and 3-14% for plans when the least and median offset histories were applied.

CONCLUSION

The successful implementation of H&N IMRT requires accurate and reproducible treatment delivery over a 6- to 7-week treatment course. The adverse impact of daily setup variation, which occurs routinely with conventional H&N masking techniques, may be considerably greater than recognized. Isocenter verification checks on two-dimensional orthogonal films may not sufficiently alert the clinician to the magnitude of three-dimensional offset vectors and the resultant impact on the quality of overall IMRT delivery. Unrecognized geographic miss and resultant target underdose may occur. Similarly, selected normal structures such as parotid glands may receive higher doses than intended. The results of this study suggest that more rigorous immobilization techniques than conventional masking and routine patient setup tracking methodologies are important for the accurate monitoring and successful delivery of high-quality IMRT for H&N cancer.

Stereotactic radiotherapy for treatment of cavernous sinus meningiomas

PURPOSE

To assess the safety and efficacy of stereotactic radiotherapy (SRT) using a linear accelerator equipped with a micromultileaf collimator for cavernous sinus meningiomas.

METHODS AND MATERIALS

Forty-five patients with benign cavernous sinus meningiomas were treated with SRT between November 1997 and April 2002. Sixteen patients received definitive treatment on the basis of imaging characteristics of the cavernous sinus tumor. Twenty-nine patients received SRT either as immediate adjuvant treatment after incomplete resection or at documented recurrence. Treatment planning in all patients included CT-MRI image fusion and beam shaping using a micromultileaf collimator. The primary tumor volume varied from 1.41 to 65.66 cm(3) (median, 14.5 cm(3)). The tumor diameter varied from 1.4 to 7.4 cm (median, 3.8 cm). Tumor compressed the optic chiasm or optic nerve in 30 patients. All tumors were treated with a single isocenter plus a margin of normal parenchyma varying from 1 to 5 mm (median, 2.5 mm). The prescribed dose varied from 4250 to 5400 cGy (median, 5040 cGy). The prescription isodose varied from 87% to 95% (median, 90%). The maximal tumor dose varied from 5000 to 6000 cGy (median, 5600 cGy). The follow-up varied from 12 to 53 months (median, 36 months).

RESULTS

The actuarial 3-year overall and progression-free survival rate was 100% and 97.4%, respectively. One patient (2%) developed local relapsed at 18 months. A partial imaging response occurred in 18% of patients, and the tumor was stable in the remaining 80%. Preexisting neurologic complaints improved in 20% of patients and were stable in the remainder. No patient, tumor, or treatment factors were found to be predictive of imaging or clinical response. Transient acute morbidities included headache responsive to nonnarcotic analgesics in 4 patients, fatigue in 3 patients, and retroorbital pain in 1 patient. No treatment-induced peritumoral edema, cranial neuropathy, endocrine dysfunction, cognitive decline, or second malignancy occurred. One patient had an ipsilateral cerebrovascular accident 6 months after SRT.

CONCLUSION

Stereotactic radiotherapy is both safe and effective for patients with cavernous sinus meningiomas. Field shaping using a micromultileaf collimator allows conformal and homogeneous radiation of cavernous sinus meningiomas that may not be amenable to single-fraction stereotactic radiosurgery because of tumor size or location. Additional clinical experience is necessary to determine the position of SRT among the available innovative fractionated RT options for challenging skull base meningiomas.