Comparative Analysis of Efficacy and Safety of Multisession Radiosurgery to Single Dose Radiosurgery for Metastatic Brain Tumors

( Gwang Soo Lee ),( Sung Jin Cho ),( Ji Hoon Kim ),( Hyung Ki Park ),( Suk Que Park ),( Ra Sun Kim ),( Jae Chil Jang ) 대한뇌종양학회·대한신경종양학회·대한소아뇌종양학회 2015 Brain Tumor Research and Treatment Vol.3 No.2

Background The purpose of this study is to compare the efficacy and safety of multisession radiosurgery to those of single dose radiosurgery for metastatic brain tumors. Methods Between February 2008 and February 2012, 90 patients with 196 metastatic brain tumors were treated with cyberknife radiosurgery, and we reviewed these patients retrospectively. Among them, 57 patients underwent single dose radiosurgery, and 33 patients multisession radiosurgery. Tumors involving the eloquent area and large tumors (>5 cc) were treated with multisession radiosurgery. The median tumor volume and the median treatment dose of single dose radiosurgery were 2.05±0.72 cc and 19.76±1.54 Gy respectively, and in the case of multisession radiosurgery, 5.30±1.70 cc and 29.6±1.70 Gy respectively. The frequency of multisession dose was 3 to 5 times, on average 3.55 times, and 8.91 Gy were given per 1 session on average. Results The overall survival (OS) of multisession radiosurgery was 16.0 months, whereas that of single dose radiosurgery was 11.5 months. The radiologic tumor response rates were 90% in single dose radiosurgery and 95.4% in multisession radiosurgery, respectively. Over 6-month and 1-year periods, the OS rates of single dose radiosurgery were 71.4% and 44.9%, whereas those of multisession radiosurgery were 69.1% and 58.3%, respectively (p=0.83). Toxicities were seen in 18.1% in the single dose radiosurgery group versus 4% in the multisession radiosurgery group. The difference was significant (p<0.05). Conclusion In this study, the multisession radiosurgery group, despite the location and size constraints, did not differ from the single dose radiosurgery group when comparing the survival and recurrence rates, but complications and toxicity were lower. Thus, multisession radiosurgery is thought to be beneficial for treatment of large tumors and tumors located in the eloquent area.

Novalis system을 이용한 정위적 방사선 수술

최찬영,이동준,이기택,손문준,황금철,황충진 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.1

■ Objective Stereotactic radiosurgery premises excellent tumor control and minimal risk in the treatment of various intracranial tumors or vascular malformations in risky surgical locations such as cavernous sinus Moreover. it offers superior local control rates of many metastatic tumors and has promise as an adjuvant boost in certain malignant gliomas. The purpose of this study is to evaluate the efficacy of LINAC based Novalis shaped beam radiosurgery. ■ Methods and materials Between Dec. 2000 and Mar. 2002. 56 patients (86 lesions) with various intracranial tumors and vascular malformations were treated with stereotactic radiosurgery(SRS) using Novalis. 46 patients were diagnosed by prior surgical resection, biopsy or cerebral angiographic finding. 1 patient of lymphoma and 5 patients of malignant glioma, 4 patients of metastatic brain tumor had also received conventional external radiotherapy previously. The patients who underwent SRS were acoustic schwannoma(12), AVM(9), recurrent meningioma(11), cerebral metastases(12), spinal neurofibroma(1), residual spinal schwannoma(1), recurrent or residual malignant glioma(5), lymphoma(3) and others(5). The mean volume(cc) and marginal dose(Gy) were 5.7 /12 in acoustic schwannoma, 5.1/ 16 in meningioma, 8/12 in malignant glioma, 3/24 in AVM. 4/14 in lymphoma, 5/l8 in metastatic tumor. The radiographic follow up period ranged from 1 month to 17 months. ■ Results Of 56 patients treated with SRS, 9, 27, 20 patients were vascular malformation, benign tumor, malignant tumor respectively. Of 27 patients with benign tumor, 26 patients(96%) showed slight regression or no change In its size. Although only one patient of 12 acoustic schwannomas showed progression of tumor size, we considered that it was cystic degeneration with reactive swelling in 17 months post SRS radiosurgery because there was loss of central enhancement in tumor. The others did not show tumor progression. One of 9 AVMs showed nearly total obliteration of nidus in post SRS 15 months. The other AVMs were still observed. We have treated one spinal neurofibroma through extracranial stereotactic system(Exactrac) and the follow up study showed decrease in the degree of enhancement and slight decrease in its site. ■ Conclusions Although the follow up period of this study is rather short, stereotactic radiosurgery using Novalis is comparable to other radiosurgery modalities such as gamma knife and also may promise the efficacy of treatment about certain specific extracranial tumors.

입체적횡다중회전조사를 병합한 방사선수술의 새로운 접근

최태진(Tae Jin Choi),김진희(Jin Hee Kim),김옥배(Ok Bae Kim) 대한방사선종양학회 1996 Radiation Oncology Journal Vol.14 No.2

목 적: 선형가속기의 광자선을 이용한 두개내 소병변의 방사선수술에서 다중회전조사와 횡다중회전조사를 병용한 방사선 수술방법을 개발하고, 컴퓨터단층영상을 재구성한 방사선수술계획을 통해 선량분포를 비교하여 병변이외 정상조직의 선량을 줄이기 위한 선량변수를 구하였다. 대상 및 방법: 선형가속기 6 MV 광자선을 이용하여 치료대 각과 선원지지체 회전 및 환자체위변위를 이용한 입체적 다중 및 횡다중회전조사를 조사하여 선량분포를 비교하였다. 입체적 선량분포와 횡단면, 시상면 및 관상면 치료대 영상재구성의 선량분포는 본 대학에서 개발한 방사선수술기구 및 소프트웨어 (Photon Knife)를 통해 이루어졌다. 입체적 다중회전조사에 의해 얻은 선량은 치료대 각이 20, 60, 120, 160도, 각각의 선원지지체 회전각은 20-160도이며, 다중회전조사의 치료대각 30, 150도와 횡다중회전조사의 치료대각 30, 150도에 선원 회전각 20-160도를 입체조사하여 비교하였다. 결 과: 선형가속기를 이용한 방사선수술선량분포는 동일 콜리메이터에서도 치료대와 선원지체 각에 따라 크게 변하였다. 입체횡다중회전조사를 시행한 경우 표적을 중심으로 전후방향의 선량분포는 다중회전조사만을 사용한 경우보다 선량기울기가 증가하여 정상뇌조직의 손상을 더 감소시킬 수 있음을 알 수 있었으며, 병변주위의 치명장기 위치에 따라 방사선 회전 방향을 적절히 정할 수 있다. 방사선수술의 입체선량과 주위 장기 및 표적의 On-Target 입체와는 방사선수술의 정확성, 복수개의 표적중심결정과 주위정상장기의 선량포함범위를 비교적 정확하게 보여줌을 알 수 있다. 결 론: 방사선수술선량계획의 입체화는 선량과 표적 및 부위장기의 선량범위를 입체적으로 정할 뿐만 아니라, 표적의 모양이 불규칙형일 때는 복수개의 표적중심결정에 필수적임을 알 수 있었다. 다중회전조사와 횡다중회전조사를 병합한 방사선수술은 표적주위의 치명정상장기의 손상을 줄이기 위해 총회전각의 변화없이 치명장기에 도달된 선량을 줄일 수 있으며, 25 mm 직경의 콜리메이터를 사용한 선량분포는 80-50%의 간격이 1.1~3.0mm, 90~50 %는 2.0~3.0mm를 나타내었다. Purpose: To get an acute steepness of dose gradients at outside the target volume in intracranial lesion and a less limitation of beam selection avoiding the high dose at normal brain tissue, this Photon Knife Radiosurgery System was developed in order to provide the three-dimensional dose distribution through the reconstruction of CT scan and the combined stereotactic tranmultiarc beam mode based on linear accelerator photon beam. Materials and Methods: This stereotactic radiosurgery, Photon Knife based on linear accelerator photon beam was provided the non-coplanar multiarc and trans-multiarc irradiations. The stereotactic trans-multiarc beam mode can be obtained from the patient position in decubitus. This study has provided the 3-dimensional isodose curve and anatomical structures with the surface rendering technique. The dose distribution from the combined two trans-multiarcs (2M 2TM) was compared to that of four non-coplanar multiarcs (4M) with same collimator size of 25mm in a diameter and total gantry movements. Results: In this study, it shows that the dose distributions of stereotactic beam mode are significantly depended on the selected couch and gantry angle in same collimator size. Practical dose distribution of combined stereotactic trans-multiarc beam has shown a more small rim thickness than that of the non-coplanar multiarc beam mode in axial, sagittal and coronal plane in our study. 3-Dimensional dose line displayed with surface rendering of irregular target shape is helpful to determine the target dose and to predict the prognosis in follow-up radiosurgery. Conclusion: 3-Dimensional dose line displayed with surface rendering of irregular target shape is essential in stereotactic radiosurgery. This combined stereotactic trans-multiarc beam has shown a less limitation of the selection couch and gantry beam angles for the target surrounding critical organs. It has shown that the dose distribution of combined trans-multiarc beam greatly depended on the couch and gantry angles. In our experiments, the absorbed dose has been decreased to 27%/mm in maximum at the interval of 50% to 80% of isodose line.

Dose Characteristics of Stereotactic Radiosurgery in High Energy Linear Accelerator Proton Beam

최태진,김옥배,Choi, Tae-Jin,Kim, Ok-Bae The Korean Society for Radiation Oncology 1992 Radiation Oncology Journal Vol.10 No.2

전산화단층촬영에 근거를 둔 3차원선량계산은 소형의 뇌종양에 대한 방사선수술에 있어서 가장 기본이 된다. 본 연구의 방사선수술 프로그램은 전산화단층촬영을 통해 표적 위치, 크기와 모양을 3차원공간에서 결정하고 최적조사면적을 구할 수 있었다. 방사선수술의 선량은 선형가속기의 6메가볼트 고에너지 광자선을 이중 비공면의 회전조사를 가상두부에 실시하여 계산된 3차원적 선량분포와 필름선량계의 실측선량을 비교한 바 거의 일치됨을 확인하였다. 본 연구의 방사선수술에서 $80\%$에서 $50\%$까지 선량곡선의 기울기는 전회전각이 1120도 일때 10 mm 조사면적에서 약 $16.7\%$/mm 였고 30 mm 에서 는 $13.0\%$/mm를 보였다. 또한 표적 주위의 선량분포는 표적내 최대선량값이 $90\%$ 에서 $50\%$ 까지 선량분포의 최대폭은 직경 10 mm조사면에서 2.3 mm를 나타내었으며, $90\%$에서 $20\%$까지의 거리는 5.6 mm를 나타내었으며, 30 mm직경의 조사면에서는 각각 3.5 mm와 9.8 mm를 보였다. 이러한 선량분포의 급격한 기울기는 방사선수술시 표적주위의 치명부위의 손상을 최소화하기 위한 선량최적화 작업에 지침이 될 것으로 생각되며, 또한 방사선수술방법의 차이에 따라 비교자료가 될 수 있을 것으로 생각된다. Three-dimensional dose calculations based on CT images are fundamental to stereotactic radiosurgery for small intracranial tumor. In our stereotactic radiosurgery program, irradiations have been performed using the 6 MV photon beam of linear accelerator after stereotactic CT investigations of the target center through the beam's-eye view and the coordinates of BRW frame converted to that of radiosurgery. Also we can describe the tumor diameter and the shape in three dimensional configuration. Non-coplanar irradiation technique was developed that it consists of a combination of a moving field with a gantry angle of $140^{\circ}$, and a horizontal couch angle of $200^{\circ}C$ around the isocenter. In this radiosurgery technique, we provide the patient head setup in the base-ring holder and rotate around body axis. The total gantry moving range shows angle of 2520 degrees via two different types of gantry movement in a plane perpendicular to the axis of patient. The 3-D isodose curves overlapped to the tumor contours in screen and analytic dose profiles in calculation area were provided to calculate the thickness of $80\%$ of tumor center dose to $20\%$ of that. Furtheremore we provided the 3-D dose profiles in entire calculation plane. In this experiments, measured isodose curves in phantom irradiation have shown very similiar to that of computer generations.

Dose Characteristics of Stereotactic Radiosurgery in High Energy Linear Acceleraor Photon Beam

최태진(Tae Jin Choi),김옥배(Ok Bae Kim) 대한방사선종양학회 1992 Radiation Oncology Journal Vol.10 No.2

전산화단층촬영에 근거를 둔 3차원선량계산은 소형의 뇌종양에 대한 방사선수술에 있어서 가장 기본이 된다. 본 연구의 방사선수술 프로그램은 전산화단층촬영을 통해 표적 위치, 크기와 모양을 3차원공간에서 결정하고 최적조사면적을 구할 수 있었다. 방사선수술의 선량은 선형가속기의 6메가볼트 고에너지 광자선을 이중 비공면의 회전조사를 가상두부에 실시하여 계산된 3차원적 선량분포와 필름선량계의 실측선량을 비교한 바 거의 일치됨을 확인하였다. 본 연구의 방사선수술에서 80%에서 50%까지 선량곡선의 기울기는 전회전각이 1120도 일 때 10 mm조사면적에서 약 16.7%/mm 였고 30mm에서는 13.0%/mm를 보였다. 또한 표적주위의 선량분포는 표적내 최대선량값이 90%에서 50%까지 선량분포의 최대폭은 직경 10mm조사면에서 2.3mm를 나타내었으며, 90%에서 20%까지의 거리는 5.6mm를 나타내었으며, 30mm직경의 조사면에서는 각각 3.5mm와 9.8mm를 보였다. 이러한 선량분포의 급격한 기울기는 방사선수술시 표적주위의 치명부위의 손상을 최소화하기 위한 선량최적화 작업에 지침이 될 것으로 생각되며, 또한 방사선수술방법의 차이에 따라 비교자료가 될 수 있을 것으로 생각된다. Three-dimensional dose calculations based on CT images are fundamental to stereotactic radiosurgery for small intracranial tumor. In our strerotactic radiosurgery program, irradiations have been performed using the 6 MV photon beam of linear accelerator after stereotactic CT investigations of the target center through the beam's-eye view and the coordinates of BRW frame converted to that of radiosurgery. Also we can describe the tumor diameter and the shape in three dimensional configuration. Non-coplanar irradiaion technique was developed that it consists of a combination of a moving field with a gantry angle of 140°, and a horizontal couch angle of 200° around the isocenter. In this radiosurgery technique, we provide the patient head setup in the base-ring holder and rotate around body axis. The total gantry moving range showa angle of 2520 degrees via two different types of gantry movement in a plane perpendicular to the axis of patient. The 3-D isodose curves overlapped to the tumor contours in screen and analytic dose profiles in calculation area were provided to calculate the thickness of 80% of tumor center dose to 20% of that. Furthermore we provided the 3-D dose profiles in entire calculation plane. In this experiments, measured isodose curves in phantom irradiation have shown very similar to that of computer generations.

Contemporary treatment with radiosurgery for spine metastasis and spinal cord compression in 2015

Samuel Ryu,Hannah Yoon,Alexander Stessin,PhD,Fred Gutman,Arthur Rosiello,Raphael Davis 대한방사선종양학회 2015 Radiation Oncology Journal Vol.33 No.1

With the progress of image-guided localization, body immobilization system, and computerized delivery of intensity-modulated radiation delivery, it became possible to perform spine radiosurgery. The next question is how to translate the high technology treatment to the clinical application. Clinical trials have been performed to demonstrate the feasibility of spine radiosurgery and efficacy of the treatment in the setting of spine metastasis, leading to the randomized trials by a cooperative group. Radiosurgery has also demonstrated its efficacy to decompress the spinal cord compression in selected group of patients. The experience indicates that spine radiosurgery has a potential to change the clinical practice in the management of spine metastasis and spinal cord compression.

Stereotactic Radiosurgery를 위한 소형 조사면의 선량측정

추성실(Sung Sil Chu),서창옥(Chang Ok Suh),노준규(John J.K Loh),정상섭(Sang Sup Chung) 대한방사선종양학회 1989 Radiation Oncology Journal Vol.7 No.1

The treatment planning and dosimetry of small fields for stereotactic radiosurgery with 10 MV x-ray isocentrically mounted linear accelerator is presented. Special consideration in this study was given to the variation of absorbed dose with field size, the central axis percent depth doses and the combined moving beam dose distribution. The collimator scatter correction factors of small fields (1x1~3x3cm²) were measured with ion chamber at a target chamber distance of 300cm where the projected fields were larger than the polystyrene buildup caps and it was calibrated with the tissue equivalent solid state detectors of small size (TLD, PLD, ESR and semiconductors). The central axis percent depth doses for 1x1 and 3x3cm² fields could be derived with the same acuracy by interpolating between measured values for larger fields and calculated zero area data, and it was also calibrated with semiconductor detectors. The agreement between experimental and calculated data was found to be under ±2% within the fields. The three dimensional dose planning of stereotactic focusing irradiation on small size tumor regions was performed with dose planning computer system (Therac 2300) and was verified with film dosimetry. The more the number of strips and the wider the angle of arc rotation, the larger were the dose delivered on tumor and the less the dose to surrounding the normal tissues. The circular cone, we designed, improves the alignment, minimizes the penumbra of the beam and formats ball shape of treatment area without stellate patterns. These dosimetric techniques can provide adequate physics background for stereotactic radiosurgery with small radiation fields and 10MV x-ray beam.

Contemporary treatment with radiosurgery for spine metastasis and spinal cord compression in 2015

Ryu, Samuel,Yoon, Hannah,Stessin, Alexander,Gutman, Fred,Rosiello, Arthur,Davis, Raphael The Korean Society for Radiation Oncology 2015 Radiation Oncology Journal Vol.33 No.1

With the progress of image-guided localization, body immobilization system, and computerized delivery of intensity-modulated radiation delivery, it became possible to perform spine radiosurgery. The next question is how to translate the high technology treatment to the clinical application. Clinical trials have been performed to demonstrate the feasibility of spine radiosurgery and efficacy of the treatment in the setting of spine metastasis, leading to the randomized trials by a cooperative group. Radiosurgery has also demonstrated its efficacy to decompress the spinal cord compression in selected group of patients. The experience indicates that spine radiosurgery has a potential to change the clinical practice in the management of spine metastasis and spinal cord compression.

Efficacy and Safety of Fractionated Stereotactic Radiosurgery for Large Brain Metastases

Jeong, Won Joo,Park, Jae Hong,Lee, Eun Jung,Kim, Jeong Hoon,Kim, Chang Jin,Cho, Young Hyun The Korean Neurosurgical Society 2015 Journal of Korean neurosurgical society Vol.46 No.6

Objective : To investigate the efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases (BMs). Methods : Between June 2011 and December 2013, a total of 38 large BMs >3.0 cm in 37 patients were treated with fractionated Cyberknife radiosurgery. These patients comprised 16 men (43.2%) and 21 women, with a median age of 60 years (range, 38-75 years). BMs originated from the lung (n=19, 51.4%), the gastrointestinal tract (n=10, 27.0%), the breast (n=5, 13.5%), and other tissues (n=3, 8.1%). The median tumor volume was 17.6 cc (range, 9.4-49.6 cc). For Cyberknife treatment, a median peripheral dose of 35 Gy (range, 30-41 Gy) was delivered in 3 to 5 fractions. Results : With a median follow-up of 10 months (range, 1-37 months), the crude local tumor control (LTC) rate was 86.8% and the estimated LTC rates at 12 and 24 months were 87.0% and 65.2%, respectively. The median overall survival (OS) and progression-free survival (PFS) rates were 16 and 11 months, respectively. The estimated OS and PFS rates at 6, 12, and 18 months were 81.1% and 65.5%, 56.8% and 44.9%, and 40.7% and 25.7%, respectively. Patient performance status and preoperative focal neurologic deficits improved in 20 of 35 (57.1%) and 12 of 17 patients (70.6%), respectively. Radiation necrosis with a toxicity grade of 2 or 3 occurred in 6 lesions (15.8%). Conclusion : These results suggest a promising role of fractionated stereotactic radiosurgery in treating large BMs in terms of both efficacy and safety.

Efficacy and Safety of Fractionated Stereotactic Radiosurgery for Large Brain Metastases

Won Joo Jeong,Jae Hong Park,Eun Jung Lee,김정훈,김창진,조영현 대한신경외과학회 2015 Journal of Korean neurosurgical society Vol.58 No.3

Objective : To investigate the efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases (BMs). Methods : Between June 2011 and December 2013, a total of 38 large BMs >3.0 cm in 37 patients were treated with fractionated Cyberknife radiosurgery. These patients comprised 16 men (43.2%) and 21 women, with a median age of 60 years (range, 38–75 years). BMs originated from the lung (n=19, 51.4%), the gastrointestinal tract (n=10, 27.0%), the breast (n=5, 13.5%), and other tissues (n=3, 8.1%). The median tumor volume was 17.6 cc (range, 9.4–49.6 cc). For Cyberknife treatment, a median peripheral dose of 35 Gy (range, 30–41 Gy) was delivered in 3 to 5 fractions. Results : With a median follow-up of 10 months (range, 1–37 months), the crude local tumor control (LTC) rate was 86.8% and the estimated LTC rates at 12 and 24 months were 87.0% and 65.2%, respectively. The median overall survival (OS) and progression-free survival (PFS) rates were 16 and 11 months, respectively. The estimated OS and PFS rates at 6, 12, and 18 months were 81.1% and 65.5%, 56.8% and 44.9%, and 40.7% and 25.7%, respectively. Patient performance status and preoperative focal neurologic deficits improved in 20 of 35 (57.1%) and 12 of 17 patients (70.6%), respectively. Radiation necrosis with a toxicity grade of 2 or 3 occurred in 6 lesions (15.8%). Conclusion : These results suggest a promising role of fractionated stereotactic radiosurgery in treating large BMs in terms of both efficacy and safety.