Karl-Heinz Höver

Stereotactic percutaneous single dose irradiation of brain metastases with a linear accelerator

The effectivity of stereotactic percutaneous single dose irradiations in the treatment of solitary brain metastases has been assessed in a series of 12 consecutive patients. Only radioresistant deeply localized metastases have been treated. Photon-irradiation was carried out with the convergent beam technique using stereotactic localization methods, in a linear accelerator facility. In 11 of the 12 patients no side effects occurred. The first 7 patients, who could be observed 3 months or longer, have been studied in detail. In each of these cases single dose irradiation with 20-30 Gy yielded arrest of tumor growth. In one case a marked decrease in contrast enhancement and in four cases shrinkage of the metastasis as well as a marked decrease of the edema occurred. In every patient a marked, sometimes dramatic improvement of the clinical condition was achieved, beginning a few days after irradiation. Stereotactic radiosurgery is a valuable tool in the treatment of inoperable, radioresistant brain metastases, the major advantage being high efficacy and smoothness of the procedure, as well as extremely short hospitalization times (2-3 days).

Long‐term follow‐up for brain metastases treated by percutaneous stereotactic single high‐dose irradiation

Surgery is considered the treatment of choice for solitary brain lesions, and radiation therapy is indicated for metastases only in vital or sensitive regions that cannot be excised without risk of disabling neurologic defects. In these cases, radiosurgery may be an alternative to conventionally fractionated radiation therapy. At the Heidelberg linear accelerator‐based radiosurgery facility, 69 patients were treated for 102 inoperable brain metastases. The primary tumor sites included non‐small cell lung carcinoma (n = 24), renal cell carcinoma (n = 14), melanoma (skin) (n = 14), colorectal carcinoma (n = 6), carcinoma of unknown primary (n = 4), and others (n = 7). Eleven patients were treated for relapse after surgery or after conventional whole‐brain irradiation. The doses at the isocenter varied from 15–50 Gy (mean, 21.5 Gy). Ten patients with multiple metastases received a planned combination of whole‐brain irradiation plus a single boost of 15 Gy. The median survival time for the entire group was 6 months, with a 1‐year‐survival of 28.3%. Factors associated with significant improvement of survival were brain metastases without other metastatic disease and good response to radiation therapy. Five of 22 patients (22.9%) with metastases located only in the brain survived longer than 2 years. An improvement in neurologic function was found in 81% within a period of 3 months. With imaging techniques, complete remission was found in 20%, partial remission in 35%, stable disease in 40%, and relapse in 5%. The authors concluded that radiosurgery is an effective and safe therapy for brain metastases. It can be applied as primary treatment, as boost in combination with whole‐brain irradiation, or as treatment for patients with relapse in a previously irradiated field.

Stereotactic single high dose radiation therapy of benign intracranial meningiomas

Seventeen patients with intracranial meningiomas were treated with single high dose irradiation at the German Cancer Research Center in Heidelberg. Indications for radiosurgery included unresected tumors, gross disease remaining despite surgery, and recurrences. Therapy was carried out by a technique using multiple non-coplanar arc irradiations from a 15 MeV linear accelerator. This technique coupled with secondary tungsten collimators allowed a high concentration of the dose in the target volume with an extremely steep dose gradient at the field borders. The patients were treated with a single irradiation dose ranging from 10 to 50 Gy (mean of 29 Gy). Four of 17 patients died: one death was tumor-related and not attributable to the treatment, one died of a treatment related complication, and two patients died of intercurrent diseases. The remaining 13 of the 17 patients with a median follow-up time of 40 months have no evidence of tumor relapse. Late severe side effects include five patients with a large area of brain edema, three of which were concurred with tumor necrosis. We conclude from these initial data that single high doses of irradiation concentrated to the tumor volume by stereotaxic methods can achieve local tumor control. It is also clear from these data that the effective therapeutic dose range must be better defined.

The role of high-dose, single-fraction irradiation in small and large intracranial arteriovenous malformations

PURPOSE Radiosurgery with external beam irradiation is an accepted treatment for small intracranial vascular malformations. It has been proven effective and safe for lesions with volumes of less than 4 cc. However, there is only some limited clinical data for malformations of grade 4 and grade 5, according to Spetzler and Martin. METHODS AND MATERIALS At the Heidelberg radiosurgery facility equipped with a linear accelerator, 212 patients with cerebral arteriovenous malformations have been treated since 1984. Thirty-eight percent of the arteriovenous malformations treated were classified inoperable, 14% grade 5, 19% grade 4, and 29% grades 1-3. Radiation doses between 10 and 29 Gy were applied to the 80% isodose contour. RESULTS Above a threshold dose of 18 Gy, the overall obliteration rate was 72%. After 3 years, the obliteration rates were 83% with volumes of less than 4.2 cc, 75% with volumes of up to 33.5 cc, and 50% with volumes of up to 113 cc. Of the patients presenting with seizures and paresis, 83% and 56%, respectively, showed improvement, which correlated with the degree of obliteration. After a follow-up period of up to 9 years, the rate of radiation-induced severe late complications was 4.3%. In grade 5 lesions, the risk of side effects was 10%. No serious complications occurred if a maximum dose of less than 25 Gy was applied to treatment volumes of less than 33.5 cc. CONCLUSION The success of stereotactic high-dose irradiation of arteriovenous malformations depends on the dose applied. The incidence of radiation-induced side effects increased with the applied dose and treatment volumes. From our experience, doses of less than 25 Gy and treatment volumes of up to 33.5 cc are safe and effective. In the future, new techniques of radiosurgery with linear accelerators and dynamically reshaped beams will allow us to apply homogenous dose distributions. Additional use of magnetic resonance angiography for 3D treatment planning will help to identify the nidus more easily.

A variety of fast neutron beams for radiobiological research

The design and construction of a new fast neutron facility and first dosimetric results obtained from seven neutron beams are presented. The neutrons are produced by bombarding beryllium targets with protons and deuterons from our K = 32 negative ion cyclotron. The dose rate in air 1 m distance from the thick target within a 13 x 13 cm2 field amounts to about 50 cGy/min at 30 microA of 32 MeV protons.

Side Effects of High-Dose Radiation Therapy of Soft-Tissue Sarcoma with 14 MeV DT Neutrons: A Correlation to Irradiated Volume

Soft-tissue sarcomas (STS) are a highly heterogeneous group of malignant tumors of mesodermal origin with some contribution from neuroectoderm. STS are classified on a histogenetic basis according to the adult tissue which they resemble, and the tumors are capable of invasive or destructive growth as well as recurrence and distant metastasis. These tumors may occur anywhere in the body, but the majority arise from the large muscles of the extremities [3]. The most important consideration in determining the patient’s prognosis and the treatment strategy is the histological grading [1, 2]. To gain local control a radical surgery is necessary [1, 6, 11, 13], but achievement of safe margins is often limited. Radiotherapy is a potent and well-accepted treatment modality. Even in those patients in whom surgical treatment was not possible, a response of the tumor and significant local control rate following high-dose irradiation has been reported [5]. Radiobiology gave reasons for the use of fast neutrons in STS. Several authors have reported superior results of neutron therapy, compared to photon therapy, especially in those patients with low-grade STS [4, 6, 7, 9–12].