Kenneth E. Ekstrand

Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis

OBJECT As a strategy to delay or avoid whole-brain radiotherapy (WBRT) after resection of a brain metastasis, the authors used high-resolution MR imaging and cavity-directed radiosurgery for the detection and treatment of further metastases. METHODS Between April 2001 and October 2009, 112 resection cavities in 106 patients with no prior WBRT were treated using radiosurgery directed to the tumor cavity and for any synchronous brain metastases detected on high-resolution MR imaging at the time of radiosurgical planning. A median dose of 17 Gy to the 50% isodose line was prescribed to the gross tumor volume, defined as the rim of enhancement around the resection cavity. Patients were followed up via serial imaging, and new brain metastases were generally treated using additional radiosurgery, with salvage WBRT typically reserved for local treatment failure at a resection cavity, numerous failures, or failures occurring at short time intervals. Local and distant treatment failures were determined based on imaging results. Kaplan-Meier curves were generated to estimate local and distant treatment failure rates, overall survival, neurological cause-specific survival, and time delay to salvage WBRT. RESULTS Radiosurgery was delivered to the resection cavity alone in 57.5% of patients, whereas 24.5% of patients also received treatment for 1 synchronous metastasis, 11.3% also received treatment for 2 synchronous metastases, and 6.6% also received treatment for 3-10 additional lesions. The median overall survival was 10.9 months. Overall survival at 1 year was 46.8%. The local tumor control rate at 1 year was 80.3%. The disease control rate in distant regions of the brain at 1 year was 35.4%, with a median time of 6.9 months to distant failure. Thirty-nine of 106 patients eventually received salvage WBRT, and the median time to salvage WBRT was 12.6 months. Kaplan-Meier estimates showed that the rate of requisite WBRT at 1 year was 45.9%. Neurological cause-specific survival at 1 year was 50.1%. Leptomeningeal failure occurred in 8 patients. One patient had treatment failure within the resection tract. Seven patients required reoperation: 2 for resection cavity recurrence, 3 for radiation necrosis, 1 for hydrocephalus, and 1 for a CSF cutaneous fistula. On multivariate analysis, a preoperative tumor diameter > 3 cm was predictive of local treatment failure. CONCLUSIONS Cavity-directed radiosurgery combined with high-resolution MR imaging detection and radiosurgical treatment of synchronous brain metastases is an effective strategy for delaying and even foregoing WBRT in most patients. This technique provides acceptable local disease control, although distant treatment failure remains significant.

Pitfalls in the use of high energy X rays to treat tumors in the lung

The problem of central axis dose reduction for high energy photon beams of small cross-sectional area traversing normal lung tissue is well known. An additional problem, which may be not as well appreciated, is the loss of electronic equilibrium on the periphery of high energy photon beams, resulting in an increase in the penumbra occurring in lung. We have compared profiles of x-ray beams ranging in energy from 4 MV to 18 MV. The profiles were measured at 10-cm depth in unit-density and lung-density (0.26) phantoms. At the highest energy the 20% to 80% physical penumbra width was measured to be 7.5 mm in the unit-density material, whereas in the lung phantom the width was 18 mm. At 4 MV the situation was reversed; that is, the penumbra was slightly smaller in the lung phantom. Most computer programs for radiation therapy treatment planning do not take into account this change in beam profile when calculating dose in the lung. As a result, unanticipated underdosing inside the field and greater dose outside the field can occur when high-energy X rays are used.

The problem of obliquely incident beams in electron-beam treatment planning.

Oblique incidence of an electron beam can alter the central axis depth dose. The incident beam can be considered to be an integration of many pencil beams or slit beams. Depending on the depth in the phantom, neighboring pencil beams may have a greater or lesser contribution to the dose at a point on the central axis compared to the contribution under normal incidence. The effect has been studied experimentally and theoretically. For 6- and 9-MeV electron beans, oblique incidence is found to produce an increased dose at shallow depths and a decreased dose at normal treatment depths.

Repeat gamma knife radiosurgery for trigeminal neuralgia.

PURPOSE Repeat gamma knife stereotactic radiosurgery (GKRS) for recurrent or persistent trigeminal neuralgia induces an additional response but at the expense of an increased incidence of facial numbness. The present series summarized the results of a repeat treatment series at Wake Forest University Baptist Medical Center, including a multivariate analysis of the data to identify the prognostic factors for treatment success and toxicity. METHODS AND MATERIALS Between January 1999 and December 2007, 37 patients underwent a second GKRS application because of treatment failure after a first GKRS treatment. The mean initial dose in the series was 87.3 Gy (range, 80-90). The mean retreatment dose was 84.4 Gy (range, 60-90). The dosimetric variables recorded included the dorsal root entry zone dose, pons surface dose, and dose to the distal nerve. RESULTS Of the 37 patients, 81% achieved a >50% pain relief response to repeat GKRS, and 57% experienced some form of trigeminal dysfunction after repeat GKRS. Two patients (5%) experienced clinically significant toxicity: one with bothersome numbness and one with corneal dryness requiring tarsorraphy. A dorsal root entry zone dose at repeat treatment of >26.6 Gy predicted for treatment success (61% vs. 32%, p = .0716). A cumulative dorsal root entry zone dose of >84.3 Gy (72% vs. 44%, p = .091) and a cumulative pons surface dose of >108.5 Gy (78% vs. 44%, p = .018) predicted for post-GKRS numbness. The presence of any post-GKRS numbness predicted for a >50% decrease in pain intensity (100% vs. 60%, p = .0015). CONCLUSION Repeat GKRS is a viable treatment option for recurrent trigeminal neuralgia, although the patient assumes a greater risk of nerve dysfunction to achieve maximal pain relief.

Clinical Experience With Radiation Therapy in the Management of Neurofibromatosis-Associated Central Nervous System Tumors

PURPOSE Patients with neurofibromatosis (NF) develop tumors of the central nervous system (CNS). Radiation therapy (RT) is used to treat these lesions. To better define the efficacy of RT in these patients, we reviewed our 20-year experience. METHODS AND MATERIALS Eighteen patients with NF with CNS tumors were treated from 1986 to 2007. Median follow-up was 48 months. Progression was defined as growth or recurrence of an irradiated tumor on serial imaging. Progression-free survival (PFS) was measured from the date of RT completion to the date of last follow-up imaging study. Actuarial rates of overall survival (OS) and PFS were calculated according to the Kaplan-Meier method. RESULTS Eighty-two tumors in 18 patients were irradiated, with an average of five tumors/patient. Median age at treatment was 25 years (range, 4.3-64 years). Tumor types included acoustic neuroma (16%), ependymoma (6%), low-grade glioma (11%), meningioma (60%), and schwanomma/neurofibroma (7%). The most common indication for treatment was growth on serial imaging. Most patients (67%) received stereotactic radiosurgery (median dose, 1,200 cGy; range, 1,000-2,400 cGy). The OS rate at 5 years was 94%. Five-year PFS rates were 75% (acoustic neuroma), 100% (ependymoma), 75% (low-grade glioma), 86% (meningioma), and 100% (schwanomma/neurofibroma). Thirteen acoustic neuromas had a local control rate of 94% with a 50% hearing preservation rate. CONCLUSIONS RT provided local control, OS, and PFS rates similar to or better than published data for tumors in non-NF patients. Radiation therapy should be considered in NF patients with imaging progression of CNS tumors.

Silicon diode dosimetry

The theory of silicon diode dosimetry is briefy reviewed with respect to operation of these diodes without reverse bias in the short-circuit current mode. The problems of temperature dependence, radiation damage, and the dependence on photon energy are discussed. Various applications of the diodes to practical radiation dosimetry are then described with a view toward pointing out the pitfalls as well as the advantages of using these diodes for dosimetry.

A film dosimetry system for use in computed tomography.

The authors describe a film dosimetry system for use in calculating the surface dose delivered by a CT scanner. Kodak XV-2 film is wrapped around a cylindrical water-filled phantom and the dose distribution is recorded. This system is easier to use than thermoluminescent dosimetry (TLD) and provides a detailed map of the dose distribution. Comparison with TLD measurements for a variety of CT scanners indicates that an accuracy of +/-15% can be achieved using this system. Dose distributions obtained with several scanners are shown.

Proton NMR relaxation times in the peripheral blood or cancer patients

The proton spin lattice relaxation time (T1) of serum and leucocytes of cancer patients and normal volunteers was measured using pulsed NMR techniques. There was no statistically significant difference in the serum T1 values of cancer patients relative to normal. An increase in T1 relative to normal values was detected in the white blood cells of patients with active leukaemia. In these patients T1 fell to normal levels after the initiation of treatment. The variation of leucocyte T1 with the course of the disease for five patients having leukaemia is presented.

Lymphocyte chromosome aberrations in partial-body fractionated radiation therapy

A relationship between lymphocyte chromosome aberration yields which occur in partial-body fractionated radiation therapy and those yields measured in vitro is derived. These calculations are applied to the case of patients undergoing radiation therapy for mammary carcinoma.

The Calculation of the Dose to Lymphocytes in External Beam Radiation Therapy

Lymphopenia is known to occur in patients undergoing external beam radiation therapy when the radiation fields encompass major blood vessels and lymphatic tissue. The dose received by the lymphocytes has up to now not been determined. We present here a general formalism for the calculation of the lymphocyte dose for a patient undergoing fractionated radiation therapy at any irradiation site. The calculation procedure is demonstrated for a typical case of pelvic irradiation.