Download - Brain radaiosurgery introduction
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WHO Classification. Louis D ; Acta Neuropathol 2007WHO Classification. Louis D ; Acta Neuropathol 2007
Introduction: Radiosurgery in brain tumourIntroduction: Radiosurgery in brain tumour
Total number of tumours Total number of tumours 132132Total number of malignant glial tumour ~ Total number of malignant glial tumour ~ 2020
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Radiation therapy Radiation therapy
Conventional RT: 1.8-2 Gy/#Majority of the tumours are treated with Conv RT
Hypofractionated RT: >2 Gy/#Mainly for palliative treatment
Radiosurgery: Single fraction high dose treatmentUsually curative intent
Fractionated Radiosurgery:Short course high dose treatmentUsually curative
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Radiosurgery: Radiosurgery: toolstools
Gamma-Knife
LA based SRS Systems
BrainLAB NovalisTrilogyTomotherapy
CyberKnife
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Gamma knifeGamma knife
• Gamma-knife: 201 Cobalt source
• Only for intracranial lesions
• Rigid/ fixed frame required
• Single fraction treatment
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Gamma-knifeGamma-knifeIndications
- Small Meningiomas (<3 cm)
- Small acuastic schwannoma (<3 cm)
- Solitary / oligo brain metastasis with controlled primary (RPA Class I)
- Small residual LGG
- AVMs (<3 cm)
- Trigeminal neuralgia (Functional disorder)
More than 40 years experience / results with Gamma-Knife
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CyberKnife: CyberKnife: Unique propertiesUnique properties
Highly precise treatment delivery
Motion management method
Tumour tracking
‘Dose painting’
Excellent dose distribution
Fractionation schedule
No rigid fixation
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‘CyberKnife is an extension of Gamma-Knife’
- Principles of ‘field arrangement’
- Dose distribution pattern
- Multiple isocentre
-Treatment principles
- Treatment delivery accuracy similar
- Delivered dose in single fractions
- Intra-cranial indications
CK & GK: Similarity
Hence, all the indications of GK are indications of CK also
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CyberknifeCyberknifeIndications for single fraction treatment as Gamma-Knife
- Small Meningiomas (<3 cm)
- Small acuastic schwannoma (<3 cm)
- Solitary / oligo brain metastasis with controlled primary
- Small residual LGG
- AVMs (<3 cm)
- Trigeminal neuralgia
- Rec High grade glioma
- Craniopharyngioma
- Pituitary tumour
More than 40 years experience / results with Gamma-Knife
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Cyberknife Vs Gamma-Knife: Cyberknife Vs Gamma-Knife: Dissimilarity
GK CK Comments
Immobilization device Rigid frame Orfit CK has favorable orfit
RT source Co60 6MV LA GK need to replace sources every 5/6 yrs
Planning No complex planning Inverse planning Favorable dosimetry in CK
Planning method Simple Complex Even neurosurgeons can plan in GK
Isodose prescription Usually 50% Usually 80-95% GK: more dose heterogeniety
Fractions Single May treat multiple fraction Radiobiology favorable in CK
Tumour size Only smaller lesions can be treated
Larger lesions also can be treated in fractionated schedule
Increased indications with CK
Energy source Radiation Electricity GK can work with less electricity
Verification Not possible Possible Even Intra-fraction movement can be corrected
Indications Only brain lesions Both extra & intra cranial CK more economical
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Cyberknife Vs Gamma-Knife: Cyberknife Vs Gamma-Knife: DissimilarityAdvantage of Inverse planning
GK planning
CK planning
Dose to mesial temporal lobe & Choclea is higher with GKMean dose to mesial temporal lobe >6 Gy with SRS: IQ decline
Romanalli, Lancet 2009
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% of patient with >10% drop in IQ% of patient with >10% drop in IQ
Left temporal lobe DVH
p=0.39
p=0.06
p=0.03
p=0.06
Vol
um
e (c
c)
Jalali , Dutta et al IJROBP 2009
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PTV margin in brain tumourPTV margin in brain tumour
CTV-PTV MarginSystemic Error (Σ)
Random Error (σ)
ICRU 62 Strooms Van Herk’s
NR only Group: Ant-Posterior 0.1 1.36 1.05 mm 1.15 mm 1.20 mm
Med-lateral 0.28 1.04 1.01 mm 1.29 mm 1.43 mm
Sup-Inferior 0.52 1.37 1.48 mm 2.0 mm 2.26 mm
NRF Group:
Ant-Posterior 2.24 1.28 3.14 mm 5.38 mm 6.50 mm
Med-lateral 0.78 1.41 1.77 mm 2.55 mm 2.94 mm
Sup-Inferior 0.94 1.39 1.91 mm 2.85 mm 3.32 mm
PTV margin: 3 mm.
Budrukkar , Dutta et al, JCRT 2008
Prospective study
Two different head rest (NR & NRF)
220images (NR 100, NRF 120)
Error estimation with 2D EPID
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Cyberknife Vs Gamma-Knife Vs X-Knife: Cyberknife Vs Gamma-Knife Vs X-Knife: CK: Accuracy similar with Gamma-Knife
Treatment delivery accuracy: GK: ~1 mm CK : ~1 mm LA based SRS: 1-2 mm (iso-centric inacurracy; LUTZ test)
PTV margin: CK: <1 mm GK: <1 mm LA based SRS: 1-2 mm GK/CK LA based SRS
CK has the accuracy of GK and flexibility of LA based SRS
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Indications for CyberKnifeIndications for CyberKnife
Intracranial tumours 1.‘oligo’ Brain metastasis
2.Acustic neuromas/ schwannomas
3.Meningiomas
4.Recurrent Low grade gliomas
5.Recurrent High grade gliomas
6. AVMs
7.Trigeminal neuralgias
8.Functional disorders
Extra-cranial tumours1.Early Non small cell lung cancer
2.Localized Prostate cancer
3.Small volume Liver cancer
4.Inoperable Gall bladder, pancreas cancer
5.Recurrent head & neck cancer
6.Recurrent Ca nasopharynx
7.‘Oligo’ Lung metastasis.
8.‘Oligo’ Liver metastasis.
9.‘Oligo’ bone metastasis
10.Eye lesions / tumours
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Radiosurgery in brain tumour: Promises Radiosurgery in brain tumour: Promises -
- Radiosurgery is a promising area in brain tumour management
-There is a definite role of radiosurgery with definite indications
-Radiosurgery is a short course, high dose radiation therapy
-Patient compliance is excellent, out-patient procedure
-CyberKnife is the most modern radiosurgery procedure