Pavel V. Houdek

Interstitial microwave hyperthermia applicators having submillimetre diameters

Using microscopic techniques we have fabricated interstitial hyperthermia applicators having diameters of 0.20, 0.33 and 0.58 mm, which will fit through catheters of 30, 26 and 22 gauge, respectively. Existing commercial applicators having a diameter of 1.1 mm required 17 gauge (or larger) catheters. Our new applicators, which operate at 915 MHz, are a smaller version of a design used by others. We have characterized our applicators by determining the energy deposition patterns (SAR) in muscle-simulating phantoms. These patterns were determined by measuring the electric field intensity using a miniature implantable isotropic probe having a diameter of 3 mm. Contours of the SAR data for our applicators, as well as a larger commercial applicator, show that all of these applicators exhibit similar heating patterns. Test results suggest that the durability and power handling capability of our submillimetre applicators are adequate for use in patients. Our new applicators should be useful in the percutaneous treatment of deep-seated tumours, intraoperative treatments, and also permit intraluminal or intravascular access to tumours.

Stereotaxic radiotherapy technique for small intracranial lesions.

A stereotaxic radiotherapy technique that permits accurate delivery of highly localized dose to a small intracranial target has been developed. The technique facilitates precise integration of the diagnostic and therapeutic procedures including target localization, treatment planning, simulation, repetitive patient irradiation, and daily treatment verification. A conventional linear accelerator and computed tomography scanner as well as special diagnostic and therapeutic guides are used. A suitable dosimetric distribution is achieved using arc therapy with small radiation fields and 10-MV x rays.

Stereotactic target point verification of an X ray and CT localizer

Stereotactic radiosurgery with a linear accelerator requires the accurate determination of a target volume and an accurate match of the therapeutic radiation dose distribution to the target volume. X ray and CT localizers have been described that are used to define the target volume or target point from angiographic or CT data. To verify the accuracy of these localizers, measurements were made with a target point simulator and an anthropomorphic head phantom. The accuracy of determining a known, high contrast, target point with these localizers was found to be a maximum of +/- 0.5 mm and +/- 1.0 mm for the X ray and CT localizer, respectively. A technique using portal X rays taken with a linear accelerator to verify the target point is also described.

Radiosurgery target point alignment errors detected with portal film verification.

Stereotactic radiosurgery with a linear accelerator requires an accurate match of the therapeutic radiation distribution to the localized target volume. Techniques for localization of the target volume using CT scans and/or angiograms have been described. Alignment of the therapeutic radiation distribution to the intended point in stereotactic space is usually accomplished using precision mechanical scales which attach to the head ring. The present work describes a technique used to verify that the stereotactic coordinates of the center of the intended radiation distribution are in agreement with the localized target point coordinates. This technique uses anterior/posterior and lateral accelerator portal verification films to localize the stereotactic coordinates of the center of the radiation distribution with the patient in the treatment position. The results of 26 cases have been analyzed. Alignment errors of the therapeutic radiation distribution in excess of 1 mm have been found using the portal film verification procedure.

Improved linac dose distributions for radiosurgery with elliptically shaped fields

Stereotactic radiosurgery techniques for a linear accelerator typically use circular radiation fields to produce an essentially spherical radiation distribution with a steep dose gradient. Target volumes are frequently irregular in shape, and circular distributions may irradiate normal tissues to high dose as well as the target volume. Improvements to the dose distribution have been made using multiple target points and optimizing the dose per arc to the target. A retrospective review of 20 radiosurgery patients has suggested that the use of elliptically shaped fields may further improve the match of the radiation distribution to the intended target volume. This hypothesis has been verified with film measurements of the radiation distribution obtained using elliptical radiation beam in a head phantom. Reductions of 40% of the high dose volume have been obtained with elliptical fields compared to circular fields without compromising the dose to the target volume.

The role of steroids in the management of metastatic carcinoma to the brain : a pilot prospective trial

This prospective study attempted to evaluate the indications for glucocorticoids which are commonly given to patients with brain metastases. Twelve patients with histologically confirmed malignancies and radiographically documented brain metastases were enrolled. Patients were scored for general performance status and neurologic function class. All subjects were given high-dose dexamethasone (HDD) for 48 hours and then randomized to receive either intermediate-dose dexamethasone (IDD) or no steroids with cranial radiotherapy. Of these 12 study patients, 3 achieved a complete response, 1 partial response, and 8 nonresponses to HDD. Seven patients had IDD, while five received no IDD. Although a small sample size prevented any statistical analysis, this study does suggest that the place for using glucocorticoids in treating patients with metastatic carcinoma to the brain remains uncertain and should be evaluated in a cooperative prospective trial.

Stereotactic radiosurgery: Dose‐volume analysis of linear accelerator techniques

Stereotactic radiosurgery of the brain may be accomplished with a linear accelerator by performing several noncoplanar arcs of a highly collimated beam focused at a point. The shape of the radiation distribution produced by this technique is affected by the beam energy, field size, and the number and size of the arcs. The influence of these parameters on the resulting radiation distributions was analyzed by computing dose volume histograms for a typical brain. Dose volume functions were computed for: (a) the energy range of 4-24 MV x rays; (b) target sizes of 1-4 cm; and (c) 1-11 arcs and dynamic rotation. The dose volume histograms were found to be dependent on the number of arcs for target sizes of 1-4 cm. However, these differences were minimal for techniques with 4 arcs or more. The influence of beam energy on the dose volume histogram was also found to be minimal.

Dosimetry of small radiation fields for 10-MV x rays

Dosimetry for 10-MV x rays has been extended to radiation fields smaller than 4 X 4 cm which may be suitable for radiation therapy of small lesions, e.g., intracranial tumors, benign or malignant. Special consideration in this study was given to (i) the variation of dose with field size (collimator and phantom scatter), (ii) the central axis percentage depth doses, and (iii) the moving-beam therapy dose distribution. We conclude that simple dosimetric techniques can provide adequate physics background for stereotaxic radiosurgery with small radiation fields and high-energy x rays.

Computer controlled stereotaxic radiotherapy system

A computer-controlled stereotaxic radiotherapy system based on a low-frequency magnetic field technology integrated with a single fixation point stereotaxic guide has been designed and instituted. The magnetic field, generated in space by a special field source located in the accelerator gantry, is digitized in real time by a field sensor that is six degree-of-freedom measurement device. As this sensor is an integral part of the patient stereotaxic halo, the patient position (x, y, z) and orientation (azimuth, elevation, roll) within the accelerator frame of reference are always known. Six parameters--three coordinates and three Euler space angles--are continuously transmitted to a computer where they are analyzed and compared with the stereotaxic parameters of the target point. Hence, the system facilitates rapid and accurate patient set-up for stereotaxic treatment as well as monitoring of patient during the subsequent irradiation session. The stereotaxic system has been developed to promote the integration of diagnostic and therapeutic procedures, with the specific aim of integrating CT and/or MR aided tumor localization and long term (4- to 7-week) fractionated radiotherapy of small intracranial and ocular lesions.

Long-Term Follow-up of Gliomas Treated with Fractionated Stereotactic Irradiation

Eighteen patients have been treated for gliomas with fractionated stereotactic linear accelerator (LINAC) irradiation. A plastic halo ring secured with skull pins allows daily attachment of the patient to the stereotactic frame mounted on the linear accelerator. The patients received 9-31 fractions of 1.8-3 Gy/fraction over periods of 20-49 days. Total doses delivered stereotactically where 16-60 Gy (90% isodose) delivered to 3-7 cm diameter tumors. The six patients with glioblastoma had a median survival of 16 months (range 7-60 months). The two patients with anaplastic astrocytoma survived 7 and 78 months. Most of the patients with high grade tumors also received other adjuant treatments. Of the ten patients with low grade gliomas, one expired 66 months after treatment, and the remainder are alive 22-82 months after treatment. One pediatric patient displayed evidence of focal radiation injury with visual loss. No patient developed initial recurrence of tumor outside the focally irradiated field. Stereotactic localization of irradiation protects surrounding brain tissue; fractionation improves the therapeutic ratio. These extended follow-up data indicate that stereotactic restriction of radiation fields in treatment of gliomas does not result in deterioration of survival results. Further investigation is warranted into the use of higher focal fractionated radiation doses to attempt to improve local control and survival.