Ashwatha Narayana

Hypofractionated Stereotactic Radiotherapy Using Intensity-Modulated Radiotherapy in Patients with One or Two Brain Metastases

Purpose: A small fraction of patients with 1–2 brain metastases will not be suitable candidates to either surgical resection or stereotactic radiosurgery (SRS) due to either their location or their size. The objective of this study was to determine the local control, survival, patterns of relapse and the incidence of brain injury following a course of hypofractionated stereotactic radiotherapy while avoiding upfront whole brain radiation therapy (WBRT) in this subgroup of patients. Methods: A Gill-Thomas removable head frame system was used for immobilization. Brain LAB software with dynamic multileaf collimator hardware was used to design and deliver an intensity-modulated radiation therapy treatment plan. A dose of 600 cGy was prescribed to the 100% isodose line that would encompass the lesion with a 3-mm margin. A total dose of 3,000 cGy was delivered in 5 fractions using 2 fractions per week. The patients were followed with neurological examination and serial MRI images done every 3 months following the procedure. Results: Twenty patients have been treated using this fractionation schedule since April 2004. The 1-year local control at the site of original disease is 70%. The complete response, partial response and stable disease at the last follow-up were 15, 30 and 45%, respectively. Two patients had local recurrence at the site of original disease, while 5 had evidence of leptomeningeal disease. Two additional patients developed new brain metastases, resulting in a 1-year brain relapse-free survival of 36% following this approach. The median overall survival was 8.5 months. Three patients (15%) developed steroid dependency lasting 3 months or longer following the procedure. Four patients (20%) needed WBRT as salvage following this approach. Conclusions: The preliminary results of hypofractionated SRS are comparable to both surgery and SRS data for solitary brain metastases in terms of local control and overall survival with acceptable morbidity in this cohort of unfavorable patients.

Image-fusion of MR spectroscopic images for treatment planning of gliomas

{sup 1}H magnetic resonance spectroscopic imaging (MRSI) can improve the accuracy of target delineation for gliomas, but it lacks the anatomic resolution needed for image fusion. This paper presents a simple protocol for fusing simulation computer tomography (CT) and MRSI images for glioma intensity-modulated radiotherapy (IMRT), including a retrospective study of 12 patients. Each patient first underwent whole-brain axial fluid-attenuated-inversion-recovery (FLAIR) MRI (3 mm slice thickness, no spacing), followed by three-dimensional (3D) MRSI measurements (TE/TR: 144/1000 ms) of a user-specified volume encompassing the extent of the tumor. The nominal voxel size of MRSI ranged from 8x8x10 mm{sup 3} to 12x12x10 mm{sup 3}. A system was developed to grade the tumor using the choline-to-creatine (Cho/Cr) ratios from each MRSI voxel. The merged MRSI images were then generated by replacing the Cho/Cr value of each MRSI voxel with intensities according to the Cho/Cr grades, and resampling the poorer-resolution Cho/Cr map into the higher-resolution FLAIR image space. The FUNCTOOL processing software was also used to create the screen-dumped MRSI images in which these data were overlaid with each FLAIR MRI image. The screen-dumped MRSI images were manually translated and fused with the FLAIR MRI images. Since the merged MRSI images were intrinsically fusedmorexa0» with the FLAIR MRI images, they were also registered with the screen-dumped MRSI images. The position of the MRSI volume on the merged MRSI images was compared with that of the screen-dumped MRSI images and was shifted until agreement was within a predetermined tolerance. Three clinical target volumes (CTVs) were then contoured on the FLAIR MRI images corresponding to the Cho/Cr grades. Finally, the FLAIR MRI images were fused with the simulation CT images using a mutual-information algorithm, yielding an IMRT plan that simultaneously delivers three different dose levels to the three CTVs. The image-fusion protocol was tested on 12 (six high-grade and six low-grade) glioma patients. The average agreement of the MRSI volume position on the screen-dumped MRSI images and the merged MRSI images was 0.29 mm with a standard deviation of 0.07 mm. Of all the voxels with Cho/Cr grade one or above, the distribution of Cho/Cr grade was found to correlate with the glioma grade from pathologic finding and is consistent with literature results indicating Cho/Cr elevation as a marker for malignancy. In conclusion, an image-fusion protocol was developed that successfully incorporates MRSI information into the IMRT treatment plan for glioma.«xa0less

Effect of MLC leaf width and PTV margin on the treatment planning of intensity-modulated stereotactic radiosurgery (IMSRS) or radiotherapy (IMSRT).

We studied the effect of MLC (multileaf collimator) leaf width and PTV (planning target volume) margin on treatment planning of intensity modulated stereotactic radiosurgery (IMSRS) or radiotherapy (IMSRT). Twelve patients previously treated with IMSRS/IMSRT were retrospectively planned with 5- and 3-mm MLC leaf widths and 3- and 2-mm PTV margins using the already contoured clinical target volume and critical structures. The same beam arrangement, planning parameters, and optimization method were used in each of the 4 plans for a given patient. Each plan was normalized so that the prescription dose covered at least 99% of the PTV. Plan indices--D(mean) (mean dose), conformity index (CI), V(70) (volume receiving >or= 70% of the prescription dose), and V(50) (volume receiving >or= 50% of the prescription dose)--were calculated from the dose-volume histograms (DVHs) of the PTV, normal tissue, and organs at risk (OARs). Hypothesis testing was performed on the mean ratios of plan indices to determine the statistical significance of the relative differences. The PTV was well covered for all plans, as no significant differences were observed for D(95), V(95), D(max), D(min), and D(mean) of the PTV. The irradiated volume was approximately 23% smaller when 2-mm instead of 3-mm PTV margin was used, but it was only reduced by approximately 6% when the MLC leaf width was reduced from 5 mm to 3 mm. For normal tissue and brainstem, V(70), V(50), and D(mean) were reduced more effectively by a decrease in MLC width, while D(mean) of optic nerve and chiasm were more sensitive to a change in PTV margin. The DVH statistics for the PTV and normal structures from the treatment plan with 5-mm MLC and 2-mm PTV margin were equal to those with 3-mm MLC and 3-mm PTV margin. PTV margin reduction is more effective in sparing the normal tissue and OARs than a reduction in MLC leaf width. For IMSRS, where highly accurate setup and small PTV margins are routinely employed, the use of 5-mm MLC is therefore less desirable.

TU‐C‐T‐617‐05: Effect of MLC Leaf Width and PTV Margin On the Treatment Planning of Intensity‐Modulated Stereotactic Radiosurgery Or Fractionated Stereotactic Radiotherapy

Purpose: To investigate the effect of MLC leaf width and PTV margin on intensity modulated radiosurgery (IMSRS) and radiostherapy (IMSRT) dose distributions. Method and Materials: Twelve patients previously treated with IMSRS or IMSRT were retrospectively planned with a 5mm or 3mm MLC leaf width and a 3mm or 2mm PTV margin using the already contoured CTV, critical structures and organs at risk (OARs). The same beam arrangement, planning parameters and plan selection criteria were used in each four plans for a given patient. Same target coverage was achieved by renormalizing each plan so that the prescription dose covered at least 99% of the PTV. Plan indexes — D max, D min, and D mean, conformity index (CI), V70, V50, D 95 and V 95 were calculated from the dose‐volume histograms of PTV, normal tissue, or OARs. Ratios of plan indexes were computed and hypotheses tests were performed on the mean ratios to determine the significance of the relative changes. Results: The PTV was well covered for all plans. The PTV was 25% smaller when 2mm instead of 3mm PTV margin was used; CI of 3mm MLC was 7% lowered than that of 5mm MLC. The decrease of MLC leaf width had a similar effect as that of PTV margin in reducing V70 and V50 of the normal tissue and D mean of brainstem by ∼10%. However, D mean of optic nerve and chiasm was more sensitive to the change of PTV margin. Conclusion: For IMSRT, the combination of 5mm MLC and 2mm PTV margin is dosimetrically equal to that of 3mm MLC and 3mm PTV margin for both PTV coverage and normal tissue sparing. The use of 5mm MLC and 2mm PTV margin for IMSRS is problematic because V70 and V5 are ∼10% higher than that of 3mm MLC and 2mm PTV margin.