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Eekers DBP, Zegers CML, Ahmed KA, Amelio D, Gupta T, Harrabi SB, Kazda T, Scartoni D, Seidel C, Shih HA, Minniti G. Controversies in neuro-oncology: Focal proton versus photon radiation therapy for adult brain tumors. Neurooncol Pract 2024; 11:369-382. [PMID: 39006517 PMCID: PMC11241386 DOI: 10.1093/nop/npae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Radiation therapy (RT) plays a fundamental role in the treatment of malignant and benign brain tumors. Current state-of-the-art photon- and proton-based RT combines more conformal dose distribution of target volumes and accurate dose delivery while limiting the adverse radiation effects. PubMed was systematically searched from from 2000 to October 2023 to identify studies reporting outcomes related to treatment of central nervous system (CNS)/skull base tumors with PT in adults. Several studies have demonstrated that proton therapy (PT) provides a reduced dose to healthy brain parenchyma compared with photon-based (xRT) radiation techniques. However, whether dosimetric advantages translate into superior clinical outcomes for different adult brain tumors remains an open question. This review aims at critically reviewing the recent studies on PT in adult patients with brain tumors, including glioma, meningiomas, and chordomas, to explore its potential benefits compared with xRT.
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Affiliation(s)
- Danielle B P Eekers
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW-School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Catharina M L Zegers
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW-School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Kamran A Ahmed
- Departments of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Dante Amelio
- Trento Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Tejpal Gupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Semi Ben Harrabi
- Department of Radiation Oncology, Heidelberg Ion Beam Therapy Center (HIT), University Hospital Heidelberg, Heidelberg, Germany
| | - Tomas Kazda
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University and Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Daniele Scartoni
- Trento Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Clemens Seidel
- Comprehensive Cancer Center Central Germany, Leipzig, Germany
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giuseppe Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
- IRCCS Neuromed, Pozzilli IS, Italy
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Ohira S, Imae T, Minamitani M, Katano A, Aoki A, Ohta T, Umekawa M, Shinya Y, Hasegawa H, Nishio T, Koizumi M, Yamashita H, Saito N, Nakagawa K. Long-term geometric quality assurance of radiation focal point and cone-beam computed tomography for Gamma Knife radiosurgery system. Radiol Phys Technol 2024; 17:389-395. [PMID: 38466497 PMCID: PMC11128398 DOI: 10.1007/s12194-024-00788-9] [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: 10/16/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 03/13/2024]
Abstract
To investigate the geometric accuracy of the radiation focal point (RFP) and cone-beam computed tomography (CBCT) over long-term periods for the ICON Leksell Gamma Knife radiosurgery system. This phantom study utilized the ICON quality assurance tool plus, and the phantom was manually set on the patient position system before the implementation of treatment for patients. The deviation of the RFP position from the unit center point (UCP) and the positions of the four ball bearings (BBs) in the CBCT from the reference position were automatically analyzed. During 544 days, a total of 269 analyses were performed on different days. The mean ± standard deviation (SD) of the deviation between measured RFP and UCP was 0.01 ± 0.03, 0.01 ± 0.03, and -0.01 ± 0.01 mm in the X, Y, and Z directions, respectively. The deviations with offset values after the cobalt-60 source replacement (0.00 ± 0.03, -0.01 ± 0.01, and -0.01 ± 0.01 mm in the X, Y, and Z directions, respectively) were significantly (p = 0.001) smaller than those before the replacement (0.02 ± 0.03, 0.02 ± 0.01, and -0.02 ± 0.01 mm in the X, Y, and Z directions, respectively). The overall mean ± SD of four BBs was -0.03 ± 0.03, -0.01 ± 0.05, and 0.01 ± 0.03 mm in the X, Y, and Z directions, respectively. Geometric positional accuracy was ensured to be within 0.1 mm on most days over a long-term period of more than 500 days.
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Affiliation(s)
- Shingo Ohira
- Department of Comprehensive Radiation Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Toshikazu Imae
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Masanari Minamitani
- Department of Comprehensive Radiation Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsushi Aoki
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Takeshi Ohta
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, USA
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Teiji Nishio
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hideomi Yamashita
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Keiichi Nakagawa
- Department of Comprehensive Radiation Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Tham BZ, Aleman D, Nordström H, Nygren N, Coolens C. Plan Assessment Metrics for Dose Painting in Stereotactic Radiosurgery. Adv Radiat Oncol 2023; 8:101281. [PMID: 37415903 PMCID: PMC10320410 DOI: 10.1016/j.adro.2023.101281] [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: 10/18/2022] [Accepted: 05/23/2023] [Indexed: 07/08/2023] Open
Abstract
Purpose As radiation therapy treatment precision increases with advancements in imaging and radiation delivery, dose painting treatment becomes increasingly feasible, where targets receive a nonuniform radiation dose. The high precision of stereotactic radiosurgery (SRS) makes it a good candidate for dose painting treatments, but no suitable metrics to assess dose painting SRS plans exist. Existing dose painting assessment metrics weigh target overdose and underdose equally but are unsuited for SRS plans, which typically avoid target underdose more. Current SRS metrics also prioritize reducing healthy tissue dose through selectivity and dose fall-off, and these metrics assume single prescriptions. We propose a set of metrics for dose painting SRS that would meet clinical needs and are calculated with nonuniform dose painting prescriptions. Methods and Materials Sample dose painting SRS prescriptions are first created from Gamma Knife SRS cases, apparent diffusion coefficient magnetic resonance images, and various image-to-prescription functions. Treatment plans are found through semi-infinite linear programming optimization and using clinically determined isocenters, then assessed with existing and proposed metrics. Modified versions of SRS metrics are proposed, including coverage, selectivity, conformity, efficiency, and gradient indices. Quality factor, a current dose painting metric, is applied both without changes and with modifications. A new metric, integral dose ratio, is proposed as a measure of target overdose. Results The merits of existing and modified metrics are demonstrated and discussed. A modified conformity index using mean or minimum prescription dose would be suitable for dose painting SRS with integral or maximum boost methods, respectively. Either modified efficiency index is a suitable replacement for the existing gradient index. Conclusions The proposed modified SRS metrics are appropriate measures of plan quality for dose painting SRS plans and have the advantage of giving equal values as the original SRS metrics when applied to single-prescription plans.
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Affiliation(s)
- Benjamin Z. Tham
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Dionne Aleman
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Catherine Coolens
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Zhang H, Wu H, Lu J, Shao W, Yu L. Combined helical tomotherapy and Gamma Knife stereotactic radiosurgery for high-grade recurrent orbital meningioma: a case report. Front Oncol 2023; 13:1273465. [PMID: 37886178 PMCID: PMC10599143 DOI: 10.3389/fonc.2023.1273465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/11/2023] [Indexed: 10/28/2023] Open
Abstract
Orbital meningioma is a rare type of orbital tumor with high invasiveness and recurrence rates, making it extremely challenging to treat. Due to the special location of the disease, surgery often cannot completely remove the tumor, requiring postoperative radiation therapy. Here, we report a case of an elderly male patient with right-sided proptosis, visual impairment, and diplopia. Imaging diagnosis revealed a space-occupying lesion in the extraconal space of the right orbit. Pathological and immunohistochemical examination of the resected tumor confirmed it as a grade 3 anaplastic meningioma. Two months after surgery, the patient complained of right eye swelling and a magnetic resonance imaging (MRI) scan showed a recurrence of the tumor. The patient received helical tomotherapy (TOMO) in the postoperative tumor bed and high-risk areas within the orbit with a total dose of 48Gy. However, there was no significant improvement in the patient's right eye swelling, and the size of the recurrent lesion showed no significant change on imaging. Gamma knife multifractionated stereotactic radiosurgery (MF-SRS) was then given to the recurrent lesion with 50% prescription dose 13.5Gy/3f, once every other day. An imaging diagnosis performed 45 days later showed that the tumor had disappeared completely. The patient's vision remained unchanged, but diplopia was significantly relieved after MF-SRS. We propose a new hybrid treatment model for recurrent orbital meningioma, where conventional radiation therapy ensures local control of high-risk areas around the postoperative cavity, and MF-SRS maximizes the radiation dose to recurrent lesion areas while protecting surrounding tissues and organs.
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Affiliation(s)
- Haomiao Zhang
- Department of Radiation Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hanfeng Wu
- Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
| | - Jianjie Lu
- Department of Radiation Physics, Harbin Medical University Cancer Hospital, Harbin, China
| | - Wencheng Shao
- Department of Radiation Physics, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lili Yu
- Department of Radiation Oncology, Harbin Medical University Cancer Hospital, Harbin, China
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5
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Ghazal M, Fager M, Samadi A, Gubanski M, Benmakhlouf H. On the stability of Leksell Vantage stereotactic head frame fixation in Gamma Knife radiosurgery: a study based on cone-beam computed tomography imaging and the High Definition Motion Management system. J Neurosurg 2023; 139:831-839. [PMID: 36640096 DOI: 10.3171/2022.11.jns221837] [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: 08/07/2022] [Accepted: 11/04/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The authors' objective was to investigate the stability of the newly introduced Vantage stereotactic frame fixation in single-fraction Gamma Knife radiosurgery. METHODS A total of 255 patients were included in this work and treated with the Vantage frame and Leksell Gamma Knife (LGK) Icon equipped with cone-beam computed tomography (CBCT) imaging. After the frame was mounted on the patient's head, a CT scan was acquired. After the patient was positioned on the couch of LGK, CBCT was acquired to verify the target position before treatment delivery. A second CBCT examination was acquired after treatment delivery to assess intrafractional motion. During treatment delivery, the High Definition Motion Management (HDMM) system was enabled to track a marker on the nose tip of the patient as a surrogate of intracranial motion. The stability of the Vantage frame was deconstructed into two parts: 1) motion between CT and the first CBCT prior to treatment delivery (CT-CBCT1), and 2) motion between CBCT procedures during treatment delivery (CBCT1-CBCT2). Transformation between CT and CBCT1 was given by Leksell GammaPlan, whereas transformation between CBCT1 and CBCT2 required mathematical processing of the transformation and coregistration matrices in the source files. RESULTS The average CT-CBCT1 displacement vector was 0.31 mm, with a range as great as 1.09 mm, and 89% and 97% of cases were within 0.5 mm and 0.7 mm, respectively. The CBCT1-CBCT2 displacement vectors averaged at 0.09 mm, with 97% of cases being within 0.2 mm. Spatial shift in the posterior direction was evident, with 94% of cases demonstrating this trend and averaging 0.05 mm. This was attributed to increased pressure on the posterior fixation pins. The HDMM displacement vectors presented larger values with an average of 0.4 mm and a range as great as 1.6 mm, and 98% of cases were within 1.0 mm. The correlation between CBCT1-CBCT2 and HDMM displacements was weak, which was attributed to the high stability of the Vantage frame and consequently small target displacements coupled with the sensitivity of HDMM to face mimics. CONCLUSIONS This work demonstrated that the Vantage frame possess the same degree of submillimeter stability as the well-established Leksell Coordinate Frame G (G-frame). Displacements between CT and CBCT1 were 3 times higher than between CBCT1 and CBCT2. A suggested HDMM threshold of 1.2 mm ensures a target accuracy within 0.2 mm in Vantage frame treatments.
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Affiliation(s)
- Mohammed Ghazal
- 1Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- 2Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Marcus Fager
- 1Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Michael Gubanski
- 2Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Departments of3Neurosurgery and
- 4Radiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Hamza Benmakhlouf
- 1Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- 2Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
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Noda R, Kawashima M, Segawa M, Tsunoda S, Inoue T, Akabane A. Fractionated versus staged gamma knife radiosurgery for mid-to-large brain metastases: a propensity score-matched analysis. J Neurooncol 2023; 164:87-96. [PMID: 37525086 DOI: 10.1007/s11060-023-04374-8] [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: 05/18/2023] [Accepted: 06/14/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE To compare treatment results between fractionated gamma knife radiosurgery (f-GKRS) and staged gamma knife radiosurgery (s-GKRS) for mid-to-large brain metastases (BMs). METHODS We retrospectively analyzed data of patients with medium (4-10 mL) to large (> 10 mL) BMs who underwent s-GKRS or f-GKRS between March 2008 and September 2022. Patients were treated with (i) s-GKRS before May 2018 and (ii) f-GKRS after May 2018. Patients who underwent follow-up magnetic resonance imaging at least once were enrolled. Case-matched studies were conducted by applying propensity score matching to minimize treatment selection bias and potential confounding. Local control (LC) was set as the primary endpoint and overall survival (OS) as the secondary endpoint. RESULTS This study included 129 patients with 136 lesions and 70 patients with 78 lesions who underwent s-GKRS and f-GKRS, respectively. Overall, 124 lesions (62 lesions in each group) were selected in the case-matched group. No differences were observed in the 6-month and 1-year cumulative incidences of LC failure between the s-GKRS and f-GKRS groups (15.6% vs. 15.9% at 6 months and 25.6% vs. 25.6% at 1 year; p = 0.617). One-year OS rates were 62.6% (95% confidence interval [CI]: 45.4-75.7%) and 73.9% (95% CI: 58.8-84.2%) in the s-GKRS and f-GKRS groups, respectively. The post-GKRS median survival time was shorter in the s-GKRS group than in the f-GKRS group (17 vs. 36 months), without significance (p = 0.202). CONCLUSIONS This is the first study to compare f-GKRS and s-GKRS in large BMs. Fractionation is as effective as staged GKRS for treating mid-to-large BMs.
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Affiliation(s)
- Ryuichi Noda
- Gamma Knife Center, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan.
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan.
| | - Mariko Kawashima
- Gamma Knife Center, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, 141-8625 5-9-22, Higashi-Gotanda, Shinagawa-Ku, Tokyo, Japan
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He Z, Ho MKJ, Lee WYV, Law HY, Wong YWV, Leung TW, Mui WH, Wong ST, Wong CSF, Yam KY. Frameless versus frame-based stereotactic radiosurgery for intracranial arteriovenous malformations: A propensity-matched analysis. Clin Transl Radiat Oncol 2023; 41:100642. [PMID: 37304170 PMCID: PMC10248791 DOI: 10.1016/j.ctro.2023.100642] [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: 03/31/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
Objective The frameless linear accelerator (LINAC) based stereotactic radiosurgery (SRS) has been evolving with a reduction in patient discomfort. However, there was limited evidence comparing frame-based and frameless SRS for intracranial arteriovenous malformations (AVM). We aimed to compare the treatment outcomes between frame-based and frameless LINAC SRS. Materials and Methods This retrospective cohort compared the outcomes of frame-based LINAC SRS (1998-2009) with frameless LINAC SRS (2010-2020). The primary outcome was the obliteration rate. The other outcomes included the neurological, radiological, and functional outcomes after SRS. A matched cohort was identified by propensity scores for further comparisons. Results A total of 65 patients were included with a mean follow-up time of 13.2 years (158.5 months). There were 40 patients in the frame-based group and 25 patients in the frameless group. The overall obliteration rate was comparable (Frame-based 82.5% vs Frameless 80.0%, p = 0.310) and not significantly different over time (log-rank p = 0.536). The crude post-SRS hemorrhage rate was 1.5% and the incidence was 0.3 per 100 person-years. There were 67.7% of patients with AVM obliteration without new persistent neurological deficits at the last visit and 56.9% of patients with AVM obliteration without any deficits (transient or persistent) during the entire follow-up period. Four patients (8.0%) developed late onset persistent adverse radiation effects (more than 96 months after SRS) among 50 patients with more than 8-year surveillance. In the propensity-matched cohort of 42 patients, there was no significant difference in AVM obliteration (Frame-based vs Frameless, log-rank p = 0.984). Conclusion Frameless and frame-based LINAC SRS have comparable efficacy in intracranial AVM obliteration. A longer follow-up duration may further characterize the rate of late adverse radiation effects in frameless SRS.
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Affiliation(s)
- Zhexi He
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Man Kit Jason Ho
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Wan Yan Venus Lee
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Hing Yuen Law
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Yee Wa Victy Wong
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - To-wai Leung
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Wing Ho Mui
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Sui-To Wong
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | | | - Kwong Yui Yam
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
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Li W, Bootsma G, Shultz D, Laperriere N, Millar BA, Cho YB, Jaffray DA, Chung C, Coolens C. Assessment of intra-fraction motion during frameless image guided Gamma Knife stereotactic radiosurgery. Phys Imaging Radiat Oncol 2023; 25:100415. [PMID: 36718356 PMCID: PMC9883231 DOI: 10.1016/j.phro.2023.100415] [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: 07/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
As frameless stereotactic radiosurgery increase in use, the aim of this study was to evaluate intra-fraction motion through cone-beam CT (CBCT) and high-definition motion management (HDMM) systems. Intra-fraction motion measured between localization, repeat localization and post-treatment CBCTs were correlated to intra-faction motion indicated by the HDMM files using the Pearson coefficient (r). A total of 302 plans were reviewed from 263 patients (114 male, 149 female); 216 pairs of localization-repeat localization, and 260 localization-post-treatment CBCTs were analyzed against HDMM logs. We found the magnitude of intra-fraction motion detected by the HDMM system were larger than the corresponding CBCT results.
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Affiliation(s)
- Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada,Corresponding author at: Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Level 2B, Cobalt Lounge, Toronto, ON, Canada.
| | - Gregory Bootsma
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - David Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Barbara-Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Young Bin Cho
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David A. Jaffray
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Caroline Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Catherine Coolens
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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9
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Moon HC, Chung HT, Min BJ, Dho YS. Optimal mask fixation method for frameless radiosurgery with Leksell Gamma Knife Icon TM. J Appl Clin Med Phys 2023; 24:e13892. [PMID: 36610006 PMCID: PMC10113692 DOI: 10.1002/acm2.13892] [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: 08/17/2022] [Revised: 12/08/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023] Open
Abstract
The Leksell Gamma Knife (LGK) IconTM is used for mask-based and frame-based fixation. The mask fixation provides a noninvasive method. However, an optimal mask fixation method is yet to be established. We evaluated the characteristics of three mask fixation methods (Plain, Folded, and Wide) for the LGK IconTM . Force-sensitive resistor sensors were attached to the forehead, supraorbital, zygoma, mandible, and occipital bone of the phantom, and digital humidity and temperature sensors were attached to both temporal lobes. Cone-beam computed tomography (CBCT) and high-definition motion management (HDMM) for each mask fixation method were used to evaluate the phantom motion during the initial application. Subsequently, the mask was removed and reapplied on the second (1st reapplication) and third days (2nd reapplication). In the initial application, forces acting on most portions of the phantom were stabilized within 1.5 h. The largest force acted on the occipital bone for the Plain and Wide methods and on the mandible for the Folded method. The temperature rapidly approaches the initial temperature, whereas the humidity gradually approached the initial humidity in all fixation methods. The Folded method exhibited a significantly lower translation along the Y-axis of the Leksell coordinate system, and rotations along all axes were under 0.5°. The HDMM values remained at 0.1 mm for all fixation methods. In the reapplications, the force acting on the occipital bone was significantly greater than that during the initial application for all mask fixation methods; the temperature and humidity remained unchanged. All mask fixation methods in the 1st reapplication were not significantly different from those in the 2nd reapplication. The Folded method is recommended as an optimal mask fixation for patients who require tight fixation; the Wide method can be considered if patient comfort is a priority.
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Affiliation(s)
- Hyeong Cheol Moon
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byung Jun Min
- Department of Radiation Oncology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Department of Neurosurgery, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
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10
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Grishchuk D, Dimitriadis A, Sahgal A, De Salles A, Fariselli L, Kotecha R, Levivier M, Ma L, Pollock BE, Regis J, Sheehan J, Suh J, Yomo S, Paddick I. ISRS Technical Guidelines for Stereotactic Radiosurgery: Treatment of Small Brain Metastases (≤1 cm in Diameter). Pract Radiat Oncol 2022; 13:183-194. [PMID: 36435388 DOI: 10.1016/j.prro.2022.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The objective of this literature review was to develop International Stereotactic Radiosurgery Society (ISRS) consensus technical guidelines for the treatment of small, ≤1 cm in maximal diameter, intracranial metastases with stereotactic radiosurgery. Although different stereotactic radiosurgery technologies are available, most of them have similar treatment workflows and common technical challenges that are described. METHODS AND MATERIALS A systematic review of the literature published between 2009 and 2020 was performed in Pubmed using the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) methodology. The search terms were limited to those related to radiosurgery of brain metastases and to publications in the English language. RESULTS From 484 collected abstract 37 articles were included into the detailed review and bibliographic analysis. An additional 44 papers were identified as relevant from a search of the references. The 81 papers, including additional 7 international guidelines, were deemed relevant to at least one of five areas that were considered paramount for this report. These areas of technical focus have been employed to structure these guidelines: imaging specifications, target volume delineation and localization practices, use of margins, treatment planning techniques, and patient positioning. CONCLUSION This systematic review has demonstrated that Stereotactic Radiosurgery (SRS) for small (1 cm) brain metastases can be safely performed on both Gamma Knife (GK) and CyberKnife (CK) as well as on modern LINACs, specifically tailored for radiosurgical procedures, However, considerable expertise and resources are required for a program based on the latest evidence for best practice.
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Affiliation(s)
- Diana Grishchuk
- National Hospital for Neurology and Neurosurgery, London, United Kingdom.
| | - Alexis Dimitriadis
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, California
| | - Laura Fariselli
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unita di Radiotherapia, Milan, Italy
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Center Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurologic Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
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11
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Zero Setup Margin Mask versus Frame Immobilization during Gamma Knife ® Icon™ Stereotactic Radiosurgery for Brain Metastases. Cancers (Basel) 2022; 14:cancers14143392. [PMID: 35884453 PMCID: PMC9320023 DOI: 10.3390/cancers14143392] [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: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023] Open
Abstract
We compared the clinical outcomes of BM treated with mask immobilization with zero-SM (i.e., zero-PTV) to standard zero-SM frame immobilization SRS. Consecutive patients with BM, 0.5−2.0 cm in maximal diameter, treated with single-fraction SRS (22−24 Gy) during March 2019−February 2021 were included. Univariable and multivariable analysis were performed using the Kaplan−Meier method and Cox proportional hazards regression. A total of 150 patients with 453 BM met inclusion criteria. A total of 129 (28.5%) lesions were treated with a zero-SM mask immobilization and 324 (71.5%) with zero-SM frame immobilization. Frame immobilization treatments were associated with a higher proportion of gastrointestinal and fewer breast-cancer metastases (p = 0.024), and a higher number of treated lesions per SRS course (median 7 vs. 3; p < 0.001). With a median follow up of 15 months, there was no difference in FFLF between the mask and frame immobilization groups on univariable (p = 0.29) or multivariable analysis (p = 0.518). Actuarial FFLF at 1 year was 90.5% for mask and 92% for frame immobilization (p = 0.272). Radiation necrosis rates at 1 year were 12.5% for mask and 4.1% for frame immobilization (p = 0.502). For BM 0.5−2.0 cm in maximal diameter treated with single-fraction SRS using 22−24 Gy, mask immobilization with zero SM produces comparable clinical outcomes to frame immobilization. The initial findings support omitting a SM when using mask immobilization with this treatment approach on a Gamma Knife® Icon™.
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12
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Chew CH, Chen JC, Hung SK, Wu TH, Lee MS, Chiou WY, Chen LC, Lin HY. Clinical outcomes of benign brain tumors treated with single fraction LINAC-based stereotactic radiosurgery: Experience of a single institute. Tzu Chi Med J 2022; 34:462-472. [PMID: 36578643 PMCID: PMC9791860 DOI: 10.4103/tcmj.tcmj_260_21] [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: 09/16/2021] [Revised: 10/25/2021] [Accepted: 01/14/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives Accelerator-based stereotactic radiosurgery (SRS) is a noninvasive and effective treatment modality widely used for benign brain tumors. This study aims to report 20-year treatment outcomes in our institute. Materials and Methods From May 2001 to December 2020, 127 patients treated with LINAC-based single-fraction SRS for their benign brain lesions were included. A neurosurgeon and two radiation oncologists retrospectively reviewed all data. Computed tomography (CT) simulation was performed after head-frame fixation under local anesthesia. All planning CT images were co-registered and fused with gadolinium-enhanced magnetic resonance imaging taken within 3 months for lesions targeting and critical organs delineation. The marginal dose was prescribed at 60%-90% isodose lines, respectively, to cover ≥95% planning target volume. Outcome evaluations included clinical tumor control rate (TCR), defined as the need for salvage therapy, and radiological response, defined as no enlargement of >2 cm in the maximal diameter. Overall survival (OS) and adverse reaction (defined according to CTCAE 5.0) were also analyzed. Results The present study included 76 female and 51 male patients for analysis. The median age was 59 years (range, 20-88 years). Their diagnoses were vestibular schwannoma (VS, n = 54), nonvestibular cranial nerve schwannoma (n = 6), meningioma (n = 50), and pituitary adenoma (n = 17). Totally 136 lesions were treated in a single fraction, predominantly skull base tumors, accounting for 69.1%. Median and mean follow-up duration was 49 and 61 months (range, 1-214 months), Overall TCR was 92.9%. The 5-year disease-specific TCR for VS, nonvestibular schwannoma, meningioma, and pituitary adenoma were 97.4%, 91.7%, 93.8%, and 83.3%. Salvage therapy was indicated for eight patients at 4-110 months after SRS. Among symptomatic patients, post-SRS symptom(s) was improved, stable, and worse in 68.2%, 24.3%, and 3.6%, respectively. Radiological response rate for 111 evaluable patients was 94.6% (shrinkage, 28.8%; stable, 65.8%). OS was 96.1% without treatment-related mortality. One patient with post-SRS cranial nerve injury (0.8%, involving the trigeminal nerve, grade 2 toxicities). No grade 3-4 acute or late toxicity was found. Conclusion Our results suggested that LINAC-based SRS effectively controls tumor growth and tumor-related neurological symptoms for patients with benign brain tumors. SRS is less aggressive, associated with low neurological morbidity and no mortality. Continuous follow-up is indicated to conclude longer outcomes.
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Affiliation(s)
- Chia-Hui Chew
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Jin-Cherng Chen
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tsung-Hsien Wu
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan,Institute of Molecular Biology, National Chung Cheng University, Chiayi, Taiwan,Address for correspondence: Dr. Hon-Yi Lin, Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2, Min-Sheng Road, Dalin, Chiayi, Taiwan. E-mail:
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13
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Moon HC, Park SJ, Kim YD, Kim KM, Kang H, Lee EJ, Kim MS, Kim JW, Kim YH, Park CK, Kim YG, Dho YS. Navigation of frameless fixation for gamma knife radiosurgery using fixed augmented reality. Sci Rep 2022; 12:4486. [PMID: 35296720 PMCID: PMC8927150 DOI: 10.1038/s41598-022-08390-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022] Open
Abstract
Augmented reality (AR) offers a new medical treatment approach. We aimed to evaluate frameless (mask) fixation navigation using a 3D-printed patient model with fixed-AR technology for gamma knife radiosurgery (GKRS). Fixed-AR navigation was developed using the inside-out method with visual inertial odometry algorithms, and the flexible Quick Response marker was created for object-feature recognition. Virtual 3D-patient models for AR-rendering were created via 3D-scanning utilizing TrueDepth and cone-beam computed tomography (CBCT) to generate a new GammaKnife Icon™ model. A 3D-printed patient model included fiducial markers, and virtual 3D-patient models were used to validate registration accuracy. Registration accuracy between initial frameless fixation and re-fixation navigated fixed-AR was validated through visualization and quantitative method. The quantitative method was validated through set-up errors, fiducial marker coordinates, and high-definition motion management (HDMM) values. A 3D-printed model and virtual models were correctly overlapped under frameless fixation. Virtual models from both 3D-scanning and CBCT were enough to tolerate the navigated frameless re-fixation. Although the CBCT virtual model consistently delivered more accurate results, 3D-scanning was sufficient. Frameless re-fixation accuracy navigated in virtual models had mean set-up errors within 1 mm and 1.5° in all axes. Mean fiducial marker differences from coordinates in virtual models were within 2.5 mm in all axes, and mean 3D errors were within 3 mm. Mean HDMM difference values in virtual models were within 1.5 mm of initial HDMM values. The variability from navigation fixed-AR is enough to consider repositioning frameless fixation without CBCT scanning for treating patients fractionated with large multiple metastases lesions (> 3 cm) who have difficulty enduring long beam-on time. This system could be applied to novel GKRS navigation for frameless fixation with reduced preparation time.
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Affiliation(s)
- Hyeong Cheol Moon
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | | | | | - Kyung Min Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min-Sung Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Gyu Kim
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea.,Department of Neurosurgery, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea. .,Department of Neurosurgery, Chungbuk National University College of Medicine, Cheongju, Republic of Korea.
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14
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Régis J, Merly L, Balossier A, Baumstarck K, Hamdi H, Mariani S, Delsanti C, Vincent M, Nigoul JM, Beltaifa Y, Muracciole X. Mask-Based versus Frame-Based Gamma Knife ICON Radiosurgery in Brain Metastases: A Prospective Randomized Trial. Stereotact Funct Neurosurg 2021; 100:86-94. [PMID: 34933308 DOI: 10.1159/000519280] [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: 05/11/2021] [Accepted: 08/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Radiosurgery is performed with a diversity of instruments relying usually either on a stereotactic frame or a mask for patient head fixation. Comfort and safety efficacy of the 2 systems have never been rigorously evaluated and compared. MATERIAL AND METHOD Between February 2016 and January 2017, 58 patients presenting with nonsmall cell lung cancer brain metastases have been treated by Gamma Knife radiosurgery (GKS) with random use of a frame or a mask for fixation were included patients older than 18, with <5 brain metastases (at the exclusion of brainstem and optic pathway's locations) and no earlier history of radiotherapy. The primary outcome measure was the pain scale assessment (PSA) at the beginning of the GKS procedure. RESULTS The PSA at the beginning of the GKS procedure was not different between the 2 groups. The PSA at the day before GKS, before magnetic resonance imaging, just after frame application, and the day after radiosurgery (departure) has shown no difference between the 2 groups. At the end of the radiosurgery itself (just after frame or mask removal) and 1 h after, the mean pain scale was higher in patients treated with the frame (p < 0.05 and p < 0.001, respectively) but 2 patients were not able to tolerate the mask discomfort and had to be treated with frame. Tumor control and morbidity probability were demonstrated to be no difference between the 2 groups in this population of patients with BM not in highly functional area. The median of the extra dose to the body due to the cone-beam computed tomography was 7.5 mGy with a maximum of 35 mGy in patients treated with a mask fixation (null in the others treated with frame). Mask fixation was associated to longer treatment time although the beam on time was not different between the 2 groups. CONCLUSION In selected patients, with brain oligo-metastases out of critical location, single-dose mask-based GKS can be done with a comfort and a safety efficacy comparable to frame-based GKS. There seems to be no clear patient data that confirm the value of the mask system with regards to comfort.
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Affiliation(s)
- Jean Régis
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Louise Merly
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Anne Balossier
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Karine Baumstarck
- Department of Biostatistic, Aix Marseille University, Marseille, France
| | - Hussein Hamdi
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Sarah Mariani
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Christine Delsanti
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Marion Vincent
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Jean Marc Nigoul
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Yassin Beltaifa
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.,Department of Functional Neurosurgery, Hôpital d'Adulte de la Timone, Marseille, France
| | - Xavier Muracciole
- Department of Radiotherapy, Aix Marseille University, Marseille, France
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15
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MacDonald RL, Lee Y, Schasfoort J, Soliman H, Sahgal A, Ruschin M. Personalized treatment gating thresholds in frameless stereotactic radiosurgery using predictions of dosimetric fidelity and treatment interruption. Med Phys 2021; 48:8045-8051. [PMID: 34730238 DOI: 10.1002/mp.15331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/07/2021] [Accepted: 10/17/2021] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Gamma Knife Icon (GKI) enables a user-defined gating threshold for intrafraction motion during stereotactic radiosurgery (SRS). An optimal threshold would ensure dosimetric fidelity of the planned distribution and minimize treatment time extension by gating. A prediction of motion characteristics for a patient based on a retrospective database of motion traces could be beneficial to evaluating the choice of gating threshold. A short acquisition of motion may help to define a personalized threshold that balances dosimetric accuracy and treatment length. This study aims to evaluate the performance of a prediction of motion and the resultant dosimetric consequences for a range of motion gating thresholds. METHODS A database of 2552 motion traces (776 patients) was analyzed using previously published methods to characterize patient intrafraction motion on the GKI. For a selection of six fractionated SRS patient cases (two patients with single brain metastasis, four vestibular schwannomas), a 10-min sample of motion was used to classify motion and identify traces in the database with similar metrics. The similar motion traces were used to perform a predictive reconstruction of the selected patient's delivered dose for a range of motion thresholds. The remaining fractions were reconstructed and compared to that predicted. From the six cases, 26 fractions were used to predict the number of interruptions (n = 26), change in target coverage (n = 26), and change in brainstem maximum dose (vestibular cases only, n = 20). The difference between mean predicted and reconstructed values was compared for accuracy. RESULTS The difference between mean prediction and reconstructed values was 0.32 ± 0.38% in target coverage, 2.36 ± 5.06 interruptions, and 0.15 ± 0.24 Gy for the brainstem maximum dose. Sixty-seven of the 72 predictions (26 coverage, 26 interruptions, and 20 brainstem maximum dose) were within one standard deviation of the predicted mean. CONCLUSIONS Large databases of motion traces were used to characterize patient performance and predict motion performance. Dosimetric deterioration due to motion and extension of treatment duration can be predicted in some cases using only a short acquisition of motion and the treatment plan. This reconstruction may provide benefit in generating a patient-specific motion threshold.
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Affiliation(s)
- R Lee MacDonald
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Young Lee
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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16
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Wegner RE, Horne ZD, Liang Y, Goss M, Yu A, Pace J, Williamson RW, Leonardo J, Karlovits SM, Fuhrer R. Single Fraction Frameless Stereotactic Radiosurgery on the Gamma Knife Icon for Patients With Brain Metastases: Time to Abandon the Frame? Adv Radiat Oncol 2021; 6:100736. [PMID: 34646964 PMCID: PMC8498737 DOI: 10.1016/j.adro.2021.100736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose The latest version of the Gamma Knife, the Icon, allows for immobilization with a mask in lieu of the traditional frame during stereotactic radiosurgery. There have been some concerns regarding extent of immobilization during single fraction frameless treatment and potential effect on outcomes. As such, we reviewed outcomes in patients with brain metastases treated in a single fraction using either a frame or mask on the Gamma Knife Icon at our institution. Methods and Materials We reviewed the records of 95 patients with a total of 374 metastases treated between May 2019 and January 2021. Thirty-nine patients (41%) were treated using the Leksell frame with the remainder being immobilized with a mask. The median number of metastatic lesions was 2 (1–20). The median prescription dose was 20 Gy (11.5–24 Gy). Odds ratios were generated to identify predictors of mask use. Kaplan-Meier analysis was used to calculate survival, local failure, and distant failure rates. Cox regression was used to identify predictors of survival. Propensity matching was used to account for indication bias. Results Of the 95 patients treated, 88 (93%) had follow-up with a median duration of 5 months (1–18). Frame utilization was more likely with 6 to 10 brain metastases. Median overall survival was not reached and was 70% and 60% at 6 and 12 months for the entire cohort, respectively. There was no significant difference in survival by immobilization method (P = .12). Six patients had local failure in 10 total lesions (3 patients in each group). After propensity matching the 12 month tumor local control was 96% and 85% for framed and frameless cases, respectively (P = .07). Conclusions Frameless mask-based stereotactic radiosurgery using the Gamma Knife Icon is feasible and maintains the excellent local control seen with the use of the headframe.
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Affiliation(s)
- Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny, Pennsylvania
| | - Zachary D Horne
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny, Pennsylvania
| | - Yun Liang
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny, Pennsylvania
| | - Matthew Goss
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny, Pennsylvania
| | - Alexander Yu
- Department of Neurologic Surgery, Allegheny Health Network, Allegheny, Pennsylvania
| | - Jonathan Pace
- Department of Neurologic Surgery, Allegheny Health Network, Allegheny, Pennsylvania
| | - Richard W Williamson
- Department of Neurologic Surgery, Allegheny Health Network, Allegheny, Pennsylvania
| | - Jody Leonardo
- Department of Neurologic Surgery, Allegheny Health Network, Allegheny, Pennsylvania
| | - Stephen M Karlovits
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny, Pennsylvania
| | - Russel Fuhrer
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny, Pennsylvania
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17
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Ramachandran P, Perrett B, Dancewicz O, Seshadri V, Jones C, Mehta A, Foote M. Use of GammaPlan convolution algorithm for dose calculation on CT and cone-beam CT images. Radiat Oncol J 2021; 39:129-138. [PMID: 34619830 PMCID: PMC8497862 DOI: 10.3857/roj.2020.00640] [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: 09/01/2020] [Accepted: 04/16/2021] [Indexed: 11/05/2022] Open
Abstract
Purpose The aim of this study was to assess the suitability of using cone-beam computed tomography images (CBCTs) produced in a Leksell Gamma Knife (LGK) Icon system to generate electron density information for the convolution algorithm in Leksell GammaPlan (LGP) Treatment Planning System (TPS). Materials and Methods A retrospective set of 30 LGK treatment plans generated for patients with multiple metastases was selected in this study. Both CBCTs and fan-beam CTs were used to provide electron density data for the convolution algorithm. Plan quality metrics such as coverage, selectivity, gradient index, and beam-on time were used to assess the changes introduced by convolution using CBCT (convCBCT) and planning CT (convCT) data compared to the homogeneous TMR10 algorithm. Results The mean beam-on time for TMR10 and convCBCT was found to be 18.9 ± 5.8 minutes and 21.7 ± 6.6 minutes, respectively. The absolute mean difference between TMR10 and convCBCT for coverage, selectivity, and gradient index were 0.001, 0.02, and 0.0002, respectively. The calculated beam-on times for convCBCT were higher than the time calculated for convCT treatment plans. This is attributed to the considerable variation in Hounsfield values (HU) dependent on the position within the field of view. Conclusion The artifacts from the CBCT’s limited field-of-view and considerable HU variation need to be taken into account before considering the use of convolution algorithm for dose calculation on CBCT image datasets, and electron data derived from the onboard CBCT should be used with caution.
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Affiliation(s)
| | - Ben Perrett
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Orrie Dancewicz
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | | | - Catherine Jones
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Akash Mehta
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
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18
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Pavlica M, Dawley T, Goenka A, Schulder M. Frame-Based and Mask-Based Stereotactic Radiosurgery: The Patient Experience, Compared. Stereotact Funct Neurosurg 2021; 99:241-249. [PMID: 33550281 DOI: 10.1159/000511587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/14/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Noninvasive frameless modalities have become increasingly utilized for stereotactic radiosurgery (SRS) for benign and malignant pathologies. There is minimal comparison in the literature of frame-based (FB) and mask-based (MB) SRS. With the dual capabilities of the Elekta Gamma Knife® Icon™, we sought to compare patient perceptions of FB and MB SRS with respect to comfort and pain and to examine effects of lesion type on the patient experience of SRS. METHODS Over a 1-year period, patients who underwent single fraction, fractionated or hypofractionated FB or MB Gamma Knife SRS at our institution were given an 8-question survey about their experience with the procedure immediately after treatment was completed. Descriptive statistics were applied. RESULTS A total of 117 patients completed the survey with 65 FB and 52 MB SRS treatments. Mean pain for FB SRS (5.64 ± 2.55) was significantly greater than mean pain for MB SRS (0.92 ± 2.24; t114 = 10.46, p < 0.001). Patient comfort during the procedure was also higher for those having MB SRS (p < 0.001). Mixed results were obtained when investigating if benign versus malignant diagnosis affected patient experience of SRS. For the purposes of this study, malignant diagnoses were almost entirely metastatic lesions. Diagnosis played no role on pain levels when all patients were analyzed together. The treatment technique had no effect on patient comfort in patients with benign diagnoses, while patients with malignant diagnoses treated with MB SRS were more likely to be comfortable (p < 0.001). Among patient's receiving FB treatments, diagnosis played no role on patient comfort. When only MB treatments were analyzed, patients were more likely to be comfortable if they had a malignant lesion (p < 0.01). CONCLUSIONS Patients treated with MB SRS experience the procedure as more comfortable and less painful compared to those treated using a FB modality. Overall, this difference was not affected by a benign versus a malignant diagnosis and the treatment type is more indicative of the patient experience during SRS. A more homogenous sample between modalities and diagnoses and further follow-up with the patient's input on their experience would be beneficial.
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Affiliation(s)
- Matthew Pavlica
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
| | - Troy Dawley
- Division of Neurosurgery, Michigan State University College of Human Medicine, Southfield, Michigan, USA
| | - Anuj Goenka
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| | - Michael Schulder
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA,
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19
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Wang H, Xu Z, Grantham K, Zhou Y, Cui T, Zhang Y, Liu B, Wang X, Vergalasova I, Reyhan M, Weiner J, Danish SF, Yue N, Nie K. Performance assessment of two motion management systems for frameless stereotactic radiosurgery. Strahlenther Onkol 2021; 197:150-157. [PMID: 33047151 PMCID: PMC7840652 DOI: 10.1007/s00066-020-01688-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Frameless stereotactic radiosurgery (SRS) requires dedicated systems to monitor patient motion in order to avoid inaccurate radiation delivery due to involuntary shifts. The purpose of this study is to assess the accuracy and sensitivity of two distinct motion monitoring systems used for frameless SRS. METHODS A surface image-guided system known as optical surface monitoring system (OSMS), and a fiducial marker-based system known as high definition motion management (HDMM) as part of the latest Gamma Knife Icon® were compared. A 3D printer-based cranial motion phantom was developed to evaluate the accuracy and sensitivity of these two systems in terms of: (1) the capability to recognize predefined shifts up to 3 cm, and (2) the capability to recognize predefined speeds up to 3 cm/s. The performance of OSMS, in terms of different reference surfaces, was also evaluated. RESULTS Translational motion could be accurately detected by both systems, with an accuracy of 0.3 mm for displacement up to 1 cm, and 0.5 mm for larger displacements. The reference surface selection had an impact on OSMS performance, with flat surface resulting in less accuracy. HDMM was in general more sensitive when compared with OSMS in capturing the motion, due to its faster frame rate, but a delay in response was observed with faster speeds. Both systems were less sensitive in detection of superior-inferior motion when compared to lateral or vertical displacement directions. CONCLUSION Translational motion can be accurately and sensitively detected by OSMS and HDMM real-time monitoring systems. However, performance variations were observed along different motion directions, as well as amongst the selection of reference images. Caution is needed when using real-time monitoring systems for frameless SRS treatment.
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Affiliation(s)
- Hao Wang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Zhiyong Xu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Kevin Grantham
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Yongkang Zhou
- Department of Radiation Oncology, Zhongshan Hospital, Shanghai, China
| | - Taoran Cui
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Yin Zhang
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Bo Liu
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Xiao Wang
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Irina Vergalasova
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Meral Reyhan
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Joseph Weiner
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Shabbar F Danish
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ning Yue
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA
| | - Ke Nie
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, 195 Little Albany St., New Brunswick, NJ, USA.
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20
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Ohira S, Kanayama N, Komiyama R, Ikawa T, Toratani M, Ueda Y, Washio H, Miyazaki M, Koizumi M, Teshima T. Intra-fractional patient setup error during fractionated intracranial stereotactic irradiation treatment of patients wearing medical masks: comparison with and without bite block during COVID-19 pandemic. JOURNAL OF RADIATION RESEARCH 2021; 62:163-171. [PMID: 33392618 PMCID: PMC7717301 DOI: 10.1093/jrr/rraa101] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/22/2020] [Indexed: 05/14/2023]
Abstract
The immobilization of patients with a bite block (BB) carries the risk of interpersonal infection, particularly in the context of pandemics such as COVID-19. Here, we compared the intra-fractional patient setup error (intra-SE) with and without a BB during fractionated intracranial stereotactic irradiation (STI). Fifteen patients with brain metastases were immobilized using a BB without a medical mask, while 15 patients were immobilized without using a BB and with a medical mask. The intra-SEs in six directions (anterior-posterior (AP), superior-inferior (SI), left-right (LR), pitch, roll, and yaw) were calculated by using cone-beam computed tomography images acquired before and after the treatments. We analyzed a total of 53 and 67 treatment sessions for the with- and without-BB groups, respectively. A comparable absolute mean translational and rotational intra-SE was observed (P > 0.05) in the AP (0.19 vs 0.23 mm with- and without-BB, respectively), SI (0.30 vs 0.29 mm), LR (0.20 vs 0.29 mm), pitch (0.18 vs 0.27°), roll (0.23 vs 0.23°) and yaw (0.27 vs 22°) directions. The resultant planning target volume (PTV) margin to compensate for intra-SE was <1 mm. No statistically significant correlation was observed between the intra-SE and treatment times. A PTV margin of <1 mm was achieved even when patients were immobilized without a BB during STI dose delivery.
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Affiliation(s)
- Shingo Ohira
- Corresponding author. Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567 Osaka, Japan. Tel: +81-6-6945-1181; Fax: +81-6-6945-1900;
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Riho Komiyama
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayasu Toratani
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hayate Washio
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
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21
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Mask-based immobilization in Gamma Knife stereotactic radiosurgery. J Clin Neurosci 2020; 83:37-42. [PMID: 33339692 DOI: 10.1016/j.jocn.2020.11.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/14/2020] [Accepted: 11/23/2020] [Indexed: 11/22/2022]
Abstract
The Gamma Knife Icon (Elekta AB, Stockholm) is a cobalt-based stereotactic radiosurgery (SRS) unit to support the use of a thermoplastic mask in lieu of a rigid frame, using an onboard cone-beam CT (CBCT) and an intrafraction motion management system (IFMM). We retrospectively reviewed 124 patients treated with Gamma Knife SRS from January 2018 to December 2019 at our institution using a mask-based immobilization system. Patient and treatment characteristics were collected and summarized as well as interfraction shifts and treatment-related outcomes. This dataset includes 124 patients with an associated 358 intracranial tumors. Twenty-four patients presented with primary brain tumors, which included 14 meningiomas and 10 other histologies, with 100 patients having brain metastases. Sixty tumors were post-operative, while 298 were intact. The median dose for primary tumors was 25 Gy in 5 fractions. Median doses to metastases were 20 Gy in 1 fraction, 27 Gy in 3 fractions, and 25 Gy in 5 fractions. Median interfraction CBCT shifts were submillimeter. Median patient follow-up was 6.28 months. 91% of patients with metastases maintained local control. Our early clinical experience has demonstrated limited toxicity profiles and high patient tolerance, which suggests that mask-based Gamma Knife SRS provides a safe alternative option for frameless SRS. Patients with large target volumes where fractionation is preferred or with small target volumes in non-eloquent areas can be considered for this approach. Response rates are encouraging, and continued follow-up is necessary to investigate long-term control and survival.
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22
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Wegner RE, Xu L, Horne Z, Yu A, Goss M, Liang Y, Sohn J, Karlovits SM. Predictors of Treatment Interruption During Frameless Gamma Knife Icon Stereotactic Radiosurgery. Adv Radiat Oncol 2020; 5:1152-1157. [PMID: 33305076 PMCID: PMC7718496 DOI: 10.1016/j.adro.2020.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/16/2020] [Accepted: 06/25/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose The Gamma Knife (GK) Icon allows for the delivery of stereotactic radiosurgery using a thermoplastic mask in combination with intrafraction motion monitoring using high definition motion management. The system pauses treatment if the magnitude of motion in all directions exceeds 1 to 1.5 mm, causing a break in treatment and prolongation of the session. We reviewed the records of patients treated in a frameless manner on our GK Icon system to determine predictors for treatment interruption. Methods and Materials We reviewed the records of patients treated between May 2019 and May 2020 on the GK Icon using a frameless technique for brain metastases, gliomas, schwannomas, and meningiomas. We recorded treatment time as noted in the plan document, actual treatment delivery time, and any pauses in treatment. We tabulated baseline characteristics including age, gender, diagnosis, performance status, and shifts at time of treatment. We used a receiver operating curve analysis to determine a timepoint corresponding with treatment interruption. We then conducted a logistic regression analysis to generate odds ratios for likelihood of treatment. Results We identified 150 patients meeting inclusion criteria. The majority (82%) were patients with brain metastases. The median age was 63 and the median dose was 27 Gy (16-30 Gy) in 3 fractions (1-5 fractions). The median treatment time was 23 minutes (4-108 minutes). Sixty-nine patients (46%) had at least 1 pause in treatment (range, 1-7). Receiver operating curve analysis revealed treatment time >19 minutes and rotation >0.47 degrees to be associated with interruption. Multivariable logistic regression revealed rotation >0.47 degrees and treatment time >19 minutes as predictive of interruption. Conclusions For patients with rotations exceeding 0.47 degrees or an extended treatment time, physicians should expect treatment interruptions, consider fractionation to lessen table time, or use a frame-based approach.
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Affiliation(s)
- Rodney E. Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
- Corresponding author: Rodney E. Wegner, MD
| | - Linda Xu
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Zachary Horne
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Alexander Yu
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Matthew Goss
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Yun Liang
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Jason Sohn
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Stephen M. Karlovits
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
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23
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Joshi KC, Raghavan A, Muhsen B, Hsieh J, Borghei-Razavi H, Chao ST, Barnett GH, Suh JH, Neyman G, Kshettry VR, Recinos PF, Mohammadi AM, Angelov L. Fractionated Gamma Knife radiosurgery for skull base meningiomas: a single-institution experience. Neurosurg Focus 2020; 46:E8. [PMID: 31153152 DOI: 10.3171/2019.3.focus1963] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEGamma Knife radiosurgery (GKRS) has been successfully used for the treatment of intracranial meningiomas given its steep dose gradients and high-dose conformality. However, treatment of skull base meningiomas (SBMs) may pose significant risk to adjacent radiation-sensitive structures such as the cranial nerves. Fractionated GKRS (fGKRS) may decrease this risk, but until recently it has not been practical with traditional pin-based systems. This study reports the authors' experience in treating SBMs with fGKRS, using a relocatable, noninvasive immobilization system.METHODSThe authors performed a retrospective review of all patients who underwent fGKRS for SBMs between 2013 and 2018 delivered using the Extend relocatable frame system or the Icon system. Patient demographics, pre- and post-GKRS tumor characteristics, perilesional edema, prior treatment details, and clinical symptoms were evaluated. Volumetric analysis of pre-GKRS, post-GKRS, and subsequent follow-up visits was performed.RESULTSTwenty-five patients met inclusion criteria. Nineteen patients were treated with the Icon system, and 6 patients were treated with the Extend system. The mean pre-fGKRS tumor volume was 7.62 cm3 (range 4.57-13.07 cm3). The median margin dose was 25 Gy delivered in 4 (8%) or 5 (92%) fractions. The median follow-up time was 12.4 months (range 4.7-17.4 months). Two patients (9%) experienced new-onset cranial neuropathy at the first follow-up. The mean postoperative tumor volume reduction was 15.9% with 6 patients (27%) experiencing improvement of cranial neuropathy at the first follow-up. Median first follow-up scans were obtained at 3.4 months (range 2.8-4.3 months). Three patients (12%) developed asymptomatic, mild perilesional edema by the first follow-up, which remained stable subsequently.CONCLUSIONSfGKRS with relocatable, noninvasive immobilization systems is well tolerated in patients with SBMs and demonstrated satisfactory tumor control as well as limited radiation toxicity. Future prospective studies with long-term follow-up and comparison to single-session GKRS or fractionated stereotactic radiotherapy are necessary to validate these findings and determine the efficacy of this approach in the management of SBMs.
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Affiliation(s)
- Krishna C Joshi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | | | - Baha'eddin Muhsen
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | - Jason Hsieh
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Hamid Borghei-Razavi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | - Samuel T Chao
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and.,4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | - John H Suh
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and.,4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gennady Neyman
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and.,4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Varun R Kshettry
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | - Pablo F Recinos
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | - Alireza M Mohammadi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
| | - Lilyana Angelov
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; and
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24
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Seneviratne DS, Hadley AR, Peterson JL, Malouff TD, Reimer R, Herchko SM, May B, Ko S, Trifiletti DM, Vallow LA. Assessment of unintended shifts during frame-based stereotactic radiosurgery using cone beam computed tomography image guidance. J Neurooncol 2020; 148:273-279. [PMID: 32474748 DOI: 10.1007/s11060-020-03463-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/18/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the frequency, magnitude and possible causes of frame-shifts that may occur between treatment planning and treatment delivery when performing Gamma Knife radiosurgery with rigid frame-based immobilization. METHODS Differences between computed tomography (CT) framed fiducial stereotactic coordinate reference and cone beam computed tomography stereotactic coordinates after image registration were recorded for 49 frame-based GK radiosurgery cases performed using the Gamma Knife Icon. Parameters recorded include rotational shifts, translational shifts, and the GK-computed Maximum Shot Displacement (MSD) between the two stereotactic coordinate spaces. Other patient-specific parameters were collected and linear regression analysis was performed to evaluate predictors of increased displacement. RESULTS The median values of rotational shifts were: pitch 0.14°, yaw 0.17°, and roll 0.13°. The median absolute values of translational shifts were: left-right 0.39 mm, anteroposterior 0.14 mm, and superior-inferior 0. 22 mm. The median value of MSD was 0.71 mm. Twelve cases (24.5%) had a MSD of greater than 1.0 mm. Male gender was associated with increased MSD (p = 0.013) and translational shifts (root-mean-squared value, p = 0.017). Cases with large differences between right and left sided pin lengths were also associated with increased MSD (p = 0.011). CONCLUSIONS The use of CBCT image guidance in frame-based GK radiosurgery allows unintended frame shifts to be identified and corrected. A significant fraction (24.5%) of patients had large enough shifts to result in a MSD of greater than 1.0 mm. Male gender and eccentrically placed frames were associated with increased MSD, and particular care should be taken in these cases.
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Affiliation(s)
- Danushka S Seneviratne
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | | | - Jennifer L Peterson
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Ronald Reimer
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Steve M Herchko
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Byron May
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Stephen Ko
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA. .,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
| | - Laura A Vallow
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
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Grimm MA, Köppen U, Stieler F, Welzel G, Ruder AM, Polednik M, Wenz F, Mai SK, Giordano FA. Prospective assessment of mask versus frame fixation during Gamma Knife treatment for brain metastases. Radiother Oncol 2020; 147:195-199. [PMID: 32416280 DOI: 10.1016/j.radonc.2020.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/14/2020] [Accepted: 05/08/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE The newest generation of the Leksell Gamma Knife (GK) allows frame based as well as frameless treatment. We here report outcomes of a prospective non-randomized study on mask fixation (MF) versus frame fixation (FF) for GK treatment of brain metastases. METHODS The decision for FF or MF was made on a case-by-case basis. Factors considered were patients' preference, proximity of critical structures, V12 and treatment time. Either stereotactic radiosurgery or fractionated stereotactic radiotherapy in up to 3 fractions was performed. For MF, a PTV margin of 1 mm was added. Follow-up included quarterly MRI scans. The primary outcome was local control. Secondary endpoints were progression-free survival (PFS), overall survival (OS) and the incidence of radionecrosis. RESULTS A total of 197 lesions (169 FF and 28 MF) were treated in 76 patients (59 FF and 17 MF). 187 lesions were treated with SRS and 10 with FSRT. Median dose was 22 Gy in both groups and median follow-up was 9.3 months. There was a higher local failure rate (HR: 3.69; 95%CI: 1.13-12.0; p = 0.03) with 11 local failures in the FF and none in the MF cohort. No differences were observed between the groups for OS (median: n.r. vs. 16.9 months; HR:1.00; 95%CI: 0.41-2.46; p = 0.999) and PFS (median: 6.9 vs. 8.4 months; HR: 0.92; 95%CI: 0.47-1.79; p = 0.800). Three cases of radionecrosis occurred with FF but none with MF (p = 0.67). CONCLUSIONS Gamma Knife treatment with MF does not result in worse outcome or increased rates of radionecrosis in this non-randomized study.
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Affiliation(s)
- Mario A Grimm
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Ulrich Köppen
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Florian Stieler
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Arne Mathias Ruder
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Martin Polednik
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany; University Medical Center Freiburg, Germany
| | - Sabine K Mai
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany; Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany.
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Sebastian NT, Glenn C, Hughes R, Raval R, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Gondal H, McGregor J, Elder JB, Lonser R, Chakravarti A, Trifiletti D, Brown PD, Chan M, Palmer JD. Linear accelerator-based radiosurgery is associated with lower incidence of radionecrosis compared with gamma knife for treatment of multiple brain metastases. Radiother Oncol 2020; 147:136-143. [PMID: 32294607 DOI: 10.1016/j.radonc.2020.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gamma knife (GK) and linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) both offer excellent local control in the management of multiple brain metastases. The efficacy and toxicity of LINAC and GK SRS have not been directly compared in the modern era. We studied outcomes in patients treated with LINAC SRS and GK at two separate institutions. METHODS We identified patients treated with either LINAC or GK who were treated to ≥2 lesions and had available follow up. LINAC patients were treated using single-isocenter multitarget technique. We used Cox regression, Fine and Gray competing risks regression, and nearest neighbor propensity score matching to account for confounders and imbalance between cohorts. Kaplan-Meier curves were used to estimate overall survival and rates of radionecrosis. RESULTS We identified 391 patients who were treated in 537 courses to a total 2699 lesions (LINAC: 1014, GK: 1685). After propensity score matching, GK was associated with similar overall survival (HR = 0.86; 95% CI 0.59-1.24; p = 0.41) and higher rate of radionecrosis (HR = 3.83; 95% CI 1.66-8.84; p = 0.002) compared to LINAC. In a secondary propensity score matched analysis comparing radionecrosis in single-fraction LINAC and GK, GK remained associated with higher incidence of radionecrosis (HR = 4.42; 95% CI 1.28-15.29; p = 0.019). CONCLUSIONS In this multi-institutional study, we found similar overall survival with lower incidence of radionecrosis in patients treated with LINAC compared to GK SRS. These findings are hypothesis generating and should be validated in an independent cohort.
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Affiliation(s)
- Nikhil T Sebastian
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Jacqueline Chu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Erica H Bell
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Hasan Gondal
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - John McGregor
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - James B Elder
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Russell Lonser
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA; Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA.
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27
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MacDonald RL, Lee Y, Schasfoort J, Soliman H, Sahgal A, Ruschin M. Real-Time Infrared Motion Tracking Analysis for Patients Treated With Gated Frameless Image Guided Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2019; 106:413-421. [PMID: 31655198 DOI: 10.1016/j.ijrobp.2019.10.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE The transition from frame-based brain stereotactic radiosurgery (SRS) to frameless delivery is supported by real-time intrafraction monitoring to ensure accurate delivery. The purpose of this study is to characterize these real-time motion traces in a large cohort of patients treated with frameless gated brain SRS and to develop patient-specific predictions of tolerance violations. METHODS AND MATERIALS SRS patients treated on the Gamma Knife Icon were immobilized using a device-specific thermoplastic head mask. A motion marker was fixed to the patient's nose, with gating and cone beam computed tomography (CBCT)-based corrections to the treatment at excursions from baseline exceeding 1.5 mm. The traces of 1446 fractions were analyzed according to magnitude (932 unique treatment plans for 462 unique individual patients), directional distribution of displacement, and stability. A neural network model was developed to predict interruptions based on a subset of trace data. RESULTS The average displacement of the marker in the first fraction of all patients was 0.62 ± 0.25 mm with beam CBCT corrections, which would otherwise be modeled at 0.96 ± 0.96 mm without intrafraction motion correction (P < .0001). Twenty-nine percent of fractions delivered were interrupted, of which the Z-axis (superoinferior) motion was the largest contributor to excursion. Baseline corrections significantly compensated for the magnitude of motion in all 3 dimensions (P < .01). The motion relative to the first acquired CBCT was on average seen to consistently increase with treatment time, with the minimum P value occurring at 61.3 minutes. The neural network prediction model was able to predict treatment interruptions with 84% sensitivity on the first 5-minute sample of the trace. CONCLUSIONS Corrections to marker position significantly decreased marker excursions in all 3 axes compared with a single CBCT alignment. Patient-specific modeling may aid in the optimization of cases selected for frameless radiosurgery to increase the accuracy of planned delivery.
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Affiliation(s)
- R Lee MacDonald
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Young Lee
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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28
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Cao H, Xiao Z, Zhang Y, Kwong T, Danish SF, Weiner J, Wang X, Yue N, Dai Z, Kuang Y, Bai Y, Nie K. Dosimetric comparisons of different hypofractionated stereotactic radiotherapy techniques in treating intracranial tumors > 3 cm in longest diameter. J Neurosurg 2019; 132:1024-1032. [PMID: 30901747 DOI: 10.3171/2018.12.jns181578] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to compare the dosimetric quality of hypofractionated stereotactic radiosurgery in treating sizeable brain tumors across the following treatment platforms: GammaKnife (GK) Icon, CyberKnife (CK) G4, volumetric modulated arc therapy (VMAT) on the Varian TrueBeam STx, double scattering proton therapy (DSPT) on the Mevion S250, and intensity modulated proton therapy (IMPT) on the Varian ProBeam. METHODS In this retrospective study, stereotactic radiotherapy treatment plans were generated for 10 patients with sizeable brain tumors (> 3 cm in longest diameter) who had been treated with VMAT. Six treatment plans, 20-30 Gy in 5 fractions, were generated for each patient using the same constraints for each of the following radiosurgical methods: 1) GK, 2) CK, 3) coplanar arc VMAT (VMAT-C), 4) noncoplanar arc VMAT (VMAT-NC), 5) DSPT, and 6) IMPT. The coverage; conformity index; gradient index (GI); homogeneity index; mean and maximum point dose of organs at risk; total dose volume (V) in Gy to the normal brain for 2 Gy (V2), 5 Gy (V5), and 12 Gy (V12); and integral dose were compared across all platforms. RESULTS Among the 6 techniques, GK consistently produced a sharper dose falloff despite a greater central target dose. GK gave the lowest GI, with a mean of 2.7 ± 0.1, followed by CK (2.9 ± 0.1), VMAT-NC (3.1 ± 0.3), and VMAT-C (3.5 ± 0.3). The highest mean GIs for the proton beam treatments were 3.8 ± 0.4 for DSPT and 3.9 ± 0.4 for IMPT. The GK consistently targeted the lowest normal brain volume, delivering 5 to 12 Gy when treating relatively smaller- to intermediate-sized lesions (less than 15-20 cm3). Yet, the differences across the 6 modalities relative to GK decreased with the increase of target volume. In particular, the proton treatments delivered the lowest V5 to the normal brain when the target size was over 15-20 cm3 and also produced the lowest integral dose to the normal brain regardless of the target size. CONCLUSIONS This study provides an insightful understanding of dosimetric quality from both photon and proton treatment across the most advanced stereotactic radiotherapy platforms.
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Affiliation(s)
- Hongbin Cao
- 1Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyan Xiao
- 2Proton Therapy Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yin Zhang
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Tiffany Kwong
- 4Department of Radiological Science, University of California Irvine, Irvine, California
| | - Shabbar F Danish
- 5Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joseph Weiner
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Xiao Wang
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ning Yue
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Zhitao Dai
- 6Department of Radiation Oncology, Shanghai Hospital, The Second Military Medical University, Shanghai, China; and
| | - Yu Kuang
- 7Department of Medical Physics, University of Nevada, Las Vegas, Nevada
| | - Yongrui Bai
- 1Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ke Nie
- 3Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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