OVERVIEW OF SRS/SRT IN BRAIN TUMORS
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Stereotactic radiosurgery (SRS) is a non-invasive technique that uses precisely targeted radiation to treat tumors and abnormalities in the brain. It can deliver high doses of radiation to tumors while minimizing damage to surrounding healthy tissue. SRS uses stereotactic guidance systems and imaging to pinpoint tumors for radiation targeting in fewer treatments than traditional therapy. Common applications of SRS include treatment of brain metastases, acoustic neuromas, meningiomas, arteriovenous malformations, and pituitary tumors. Control rates for these indications are high, often over 90% depending on factors like tumor size and location.
OVERVIEW OF SRS/SRT IN BRAIN TUMORS
- 1. STEREOTACTIC RADIOTHERAPY IN BRAIN TUMORS DR KANHU CHARAN PATRO 7/28/2019 1
- 2. DEFINITION 1. Stereotactic radiosurgery (SRS) is a non- surgical radiation therapy used to treat functional abnormalities and small tumors of the brain. 2. It can deliver precisely-targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue 7/28/2019 2
- 3. WHAT IS IT? • STEREOTACTIC (GUIDING) DEVICES CAPABLE OF PINPOINTING TARGETS WITHIN THE BRAIN. • HIGH DOSE • EXACT LOCALIZATION • IMAGING DURING RADIATION 7/28/2019 3
- 5. SRS VS SRT • SRS and SRT are very similar, but SRS delivers a large dose of radiation on a single day and SRT has a fractionated treatment schedule. • This means that in a SRT treatment the patient will have treatments spanning multiple days. • Although, the total dose in SRT may be larger than in SRS any single day will have a much smaller dose delivery. 7/28/2019 5
- 6. ADVANTAGES • Decreased length of stay • Decreased cost • Rapid return to full employment • Lower immediate post treatment morbidity and mortality 7/28/2019 6
- 10. MACHINES • GAMMA KNIFE • PROTON RADIOSURGERY • X- KNIFE – CYBERKNIFE – ELEKETA – VARIAN 7/28/2019 10
- 14. X-KNIFE • TREATMENT BY HIGH ENERGY X RAYS • MOSTLY NON INVASIVE • EQUALLY EFFECTIVE • CHEAPER • AVAILABILTY 7/28/2019 14
- 18. WHAT WE HAVE? • CONES- FOR SUBCENTEMETER TUMORS • AGILITY HEAD-MORE CONFIRMITY FOR SMALLER TUMORS • FRAXION-NON INVASIVE,FRAMELESS COMFORTABLE MASK • CONE BEAM CT-ONLINE CT BASED CORRECTION • HEXAPOD-EXTRA DEGREE OF ROTATIONAL CORRECTION 7/28/2019 18
- 22. CBCT- CONE BEAM CT 7/28/2019 22
- 23. CBCT- CONE BEAM CT 7/28/2019 23
- 25. SRS SMALL FIELD CONES 7/28/2019 25
- 26. BRAIN TUMORS • MALIGNANT TUMORS • BENIGN TUMORS • FUNCTIONAL DISORDERS • REIRRADIATION 7/28/2019 26
- 27. INDICATIONS 1. AVM 2. MENINGIOMA 3. PITUITARY ADENOMA 4. ACOUSTIC NEUROMA 5. BRAIN METASTASIS 6. REIRRADIATION FOR RECURRENT GLIOMAS 7. TRIGEMINAL NEURALGIA 8. SKULL BASE TUMORS 9. SPINAL METASTASIS 10. SPINAL HEMANGIOMAS 7/28/2019 27
- 28. SUITABLE CASES • Any tumor benign or malignant less than 3cm • ELOQUENT AREAS 7/28/2019 28
- 30. ACOUSTIC NEUROMA 1. An acoustic neuroma is a noncancerous growth that develops on the eighth cranial nerve. 2. Also known as the vestibulocochlear nerve, it connects the inner ear with the brain and has two different parts. 3. One part is involved in transmitting sound; the other helps send balance information from the inner ear to the brain. 7/28/2019 30
- 31. ICE CREAM CONE 7/28/2019 31
- 34. ACOUSTIC NEUROMA-OPTIONS 1. Wait and watch 2. Surgery 3. Radio surgery 7/28/2019 34
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- 40. SURGICAL INTERVENTION • Non-elderly • Larger tumors, • Growing tumors, • Significant hearing loss, • Worse headaches 7/28/2019 40
- 44. CONTROL RATE • Long-term tumor control rates of acoustic schwannomas with radiosurgery vary from 90 % to 98 % in different series. • Chopra et al reported long-term results with acoustic schwannoma radiosurgery to 12–13 Gy for 216 patients at Pittsburgh With 98 % tumor control (freedom from resection) at 10 years 7/28/2019 44
- 45. MENINGIOMAS • Meningiomas are generally benign lesions that account for 15–20 % of primary brain tumors, affect predominately middle- aged patients, and occur predominately in females • The atypical and malignant meningiomas are characterized by successive recurrences and an aggressive behavior. • Among all meningiomas, their incidence varies in the literature ranging from 4.7 to 7.1 % and 1.0 to 3.7 % for atypical and malignant, respectively 7/28/2019 45
- 46. CASE SELECTION FOR MENINGIOMA 7/28/2019 46
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- 50. AVM 7/28/2019 50
- 51. AVM 7/28/2019 51
- 52. AVM 7/28/2019 52
- 54. SPETZLER MARTIN GRADING AVM 7/28/2019 54
- 55. AVM MANAGEMENT • Conservative • Microsurgery • Embolization • Radiosurgery 7/28/2019 55
- 56. EMBOLIZATION • Curative embolization • Partial (staged embolization) • Pre-op embolization • Pre-radiosurgery embolization 7/28/2019 56
- 57. CONSERVATIVE MX AVM • The AVM may be very extensive, located deeply with supply from deep perforating vessels which are not amenable for surgery or endovascular treatment. • Very old age would be consideration for conservative treatment. • Obviously poor medical condition, such as advanced heart diseases, respiratory insufficiency or cancer with metastasis would be contraindication to a definitive AVM treatment 7/28/2019 57
- 58. RADIOSURGERY • Radiosurgery is an effective alternative treatment for selected AVM patients rather than microsurgery , especially in those with surgically inaccessible lesions with comorbidities which hinder surgical intervention or if microsurgery is not feasible. • In terms of radiobiology, AVM are late responding target within late reaction of normal tissue. • Following bleeding , part of nidus may be hidden or compressed by clots hence it is rational to wait till resolution of hematoma (average 2-3 months). 7/28/2019 58
- 59. SPETZLER MARTIN GRADING AVM MX 7/28/2019 59
- 60. AVM MX ALGORITHM-ISRS GUIDELINES 7/28/2019 60
- 61. WHAT HAPPENES TO VESSELS 7/28/2019 61
- 62. AVM-IMAGING • DSA-DIGITAL SUBSTRACTION ANGIOGRAM • MRI – 3DFSPGR CONTRAST-BETTER BRAIN VISUALIZATION – T2W GRADIENT ECHO-DETECT BLEED • CECT-PLANNING 7/28/2019 62
- 64. STAGED VOLUME RADIOSURGERAY • Large AVMs in a planned staged fashion was undertaken to limit the radiation exposure to the surrounding normal brain • At the first radiosurgical procedure, the total volume of the AVM is estimated and a dose plan calculated that covers 10 cm3 –15 cm3 , or one-half the nidus volume if the AVM is critically located (brainstem, thalamus, or basal ganglia). • At 6-month intervals thereafter, radiosurgery was repeated to different portions of the AVM with the previous dose plan(s) being re-created utilizing intracranial landmarks to minimize radiation overlap 7/28/2019 64
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- 66. STAGED VOLUME POLLOCK ET AL/IJROBP7/28/2019 66
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- 69. PITUITARY ADENOMAS • On the evidence available, no data support the superiority of SRS over FSRT for the treatment of patients with pituitary tumors. • Dose and fractionation are usually chosen on the basis of the size and position of the pituitary adenoma. • In current clinical practice, single-fraction SRS at doses of 16–25 Gy may represent a convenient approach to patients with a relatively small pituitary adenoma away from the optic chiasm, whereas FSRT is preferred over SRS for lesions >2.5–3 cm in size and/or involving the anterior optic pathway 7/28/2019 69
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- 83. TRIGEMINAL NEURALGIA • TRIFACIAL NEURALGIA • TIC DOULOUREX • FOTHERGILLS DISEASE 7/28/2019 83
- 84. TRIGEMINAL NEURALGIA • Nearly 80 to 90% of all TN cases are caused by a neurovascular conflict involving the trigeminal nerve and an artery. • Another widely accepted cause of TN is mechanical compression of the trigeminal nerve root, usually within a few millimeters of entry into the pons—the root entry zone (REZ) • NERVE ROOT IRRITATION – Arterial compression – Demyelination 7/28/2019 84
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- 90. OPTIONS OF TREATMENT TN 1. Medications 2. Percutaneous radiofrequency rhizotomy , glycerol injection 3. Balloon compression 4. microvascular decompression (MVD) 5. Stereotactic radiosurgery (SRS) 6. Among these available techniques, SRS has emerged as the least-invasive procedure, resulting in a significant pain relief with minimal side effects 7/28/2019 90
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- 95. WHOLE BRAIN RADIOTHERAPY • LONG TERM SURVIVOURS • COGNITIVE DECLINE • QOL POOR 7/28/2019 95
- 96. BRAIN METS WITH BREAST CANCER 7/28/2019 96
- 97. BRAIN METS WITH LUNG CANCER 7/28/2019 97
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- 99. NCCN GIUDELINES BRAIN METS • Limited number (1 – 3) and stable systemic disease then surgery or radiosurgery or whole brain (with RS favored over whole brain) . • Multiple (>3) then whole brain or radiosurgery (consider RS if good performance and low overall tumor burden). 7/28/2019 99
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- 102. CHORDOMA CASE SELECTION 7/28/2019 102
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- 108. GLIOMA RECURRENCE-REIRRADIATION 18 Gy SRS salvage7/28/2019 108
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- 118. PHYSICS TEAM-THEY PLAN THE DOSE 1187/28/2019
- 122. APPLICATION IN OTHER SITES 7/28/2019 122
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