This book provides a radiotherapy perspective on the management of brain metastases with case-based discussion. This management has been rapidly evolving in the face of changing technology, progressing systemic therapy, and paradigm changes that all impact practice. These changes can be difficult, and this text gives a practical approach to help practitioners and trainees understand these changes and incorporate them into their practices.
The work has two main sections: Clinical and Technical. The clinical section has chapters that address all aspects of radiation therapy for brain metastases, including integrating advances in surgery and drug treatments. The technical section focuses on the “how to” aspects of treatment, including treatment planning and delivery.
This is an ideal guide for practicing radiation oncologists and trainees.
Author(s): Yoshiya Yamada, Eric Chang, John B. Fiveash, Jonathan Knisely
Publisher: Springer
Year: 2020
Language: English
Pages: 394
City: Cham
Foreword
Preface
Contents
Contributors
1: Introduction
References
Part I: Clinical Overview: Brain Metastases
2: Brain Metastases: Introduction
Case Vignette
Epidemiology
Risk Factors
Lung Cancer
Breast Cancer
Renal Cell Cancer (RCC)
Colorectal Cancer
Melanoma
Pathophysiology
Clinical Features
Diagnosis
Prognostic Factors
Areas of Uncertainty/Future Directions
Conclusion
References
3: Radiobiology of Stereotactic Radiosurgery
Radiobiology of Stereotactic Radiosurgery
Microvascular Effects of SBRT
Immunomodulatory Effects of SBRT
Biological Basis of Radiotherapeutic Response and Its Applicability to SRS – The 4 R’s
Redistribution or Reassortment
Reoxygenation
Repopulation
Repair of Sublethal Damage
Conclusion
References
4: Supportive Medical Management of Brain Metastases Patients Including Treatment Complications
Scope
Evidence Base
Peritumoral Cerebral Edema
Corticosteroids
Corticosteroids: Gastrointestinal Prophylaxis
Corticosteroids: Opportunistic Infections
Corticosteroids: Interactions with Immunotherapy
Cerebral Edema: VEGF Pathway Inhibition
Cerebral Edema: Experimental Treatments
Human Corticotropin-Releasing Factor (hCRF)
Neurokinin 1 Receptor Antagonism
Nonsteroidal Antiinflammatory Drugs (NSAIDs)
Selective Cyclooxygenase-2 (COX-2) Inhibition
Boswellia
Posttreatment Radiation Necrosis
Radiation Necrosis: Management
Seizures
Overview of Antiepileptic Drugs
Other Antiepileptics
Headache
Cognitive Impairment
Areas of Uncertainty and Future Directions
Conclusions and Recommendations
Case Vignettes
Vignette 1: Seizures
Vignette 2: Radiation Necrosis
References
5: Neuroimaging of Brain Metastases
Imaging of the Brain: An Overview
Neuroanatomy
Frontal and Parietal Lobes
Clinical Correlate
Temporal Lobe
Clinical Correlate
Diencephalon and Basal Ganglia
Clinical Correlate
Cerebellum
Clinical Correlate
Optic Apparatus and Sella Turcica
Clinical Correlate
Brainstem
Clinical Correlate
Skull Base: Middle Cranial Fossa
Clinical Correlate
Imaging Brain Metastases
Special Cases
Conclusions
References
6: The Evolution of Combination Therapies Involving Surgery and Radiosurgery
Case Vignette
Case 1
Case 2
Introduction
Evidence Base
Diagnosis and Management
Areas of Uncertainty/Future Directions
References
7: Laser Interstitial Thermal Therapy for Brain Metastasis
Case Vignettes
Case 1
Case 2
Introduction
Operative Technique
Diagnosis and Management
Evidence
Areas of Uncertainty in LITT for Treatment of Brain Metastasis
Complications in LITT
References
8: Integrating Systemic Therapy into the Management of Brain Metastases
Introduction
Evidence Base
General Overview Studies
Cytotoxic Agents
Platinum Analogs
Taxanes
Antimetabolites
Other Cytotoxic Agents
Molecular Targeted Agents
Case Vignette #1
VEGF Inhibitors
Case Vignette #2
Immunotherapy
RT Factors
Areas of Uncertainty and Future Directions
Case Vignette #3
Immunotherapy Imaging Response
Systemic Therapy Alone
Lymphopenia – Role of Steroids and Radiation Volume
Conclusions and Recommendations
References
9: Indications for Stereotactic Radiosurgery: Multiple Brain Metastases
Case Vignette
Case 1
Introduction
Evidence Base
Limited Metastases
Extensive Metastases
Local Tumor Control
Distant Brain Failure
Salvage Therapy
Leptomeningeal Disease
Toxicity
Neurocognition
Quality of Life
Prognostic Index
Treatment Volume
Dose Considerations
Diagnosis
Imaging
Biopsy
Management and Guidelines
Initial Management
Prognostic Index
Setup
Radiation Dose
Role for WBRT
Role for Surgery
Role for Palliative Care
Timing of SRS
Follow-Up
Areas of Uncertainty/Future Directions
Conclusions and Recommendations
Future Directions
References
10: Hypofractionated Stereotactic Radiosurgery for Intact and Resected Brain Metastases
Introduction
Limitations of Single-Fraction Radiosurgery
Radiobiology and Rationale of Hypofractionation
Clinical Experience with Hypofractionated SRS
Intact Metastases
Resection Cavities
Optimal Hypofractionated SRS Regimen
Indications for Surgery (Versus Radiosurgery) for Larger Lesions
Future Directions and Conclusions
Case Vignettes
Case 1: Postresection Cavity Hypofractionated SRS due to Size Along with Single-Fraction SRS for Small Intact Metastases
Case 2: Postresection Cavity Hypofractionated SRS over 5 Days due to Large Size
Case 3: Hypofractionated SRS over 3 Days due to Large Size and Location
References
11: Target Delineation for Radiosurgery (Including Postoperative Cavity Radiosurgery) in Brain Metastases
Case Vignettes
Case 1
Case 2
Introduction
Imaging Features of BM on CT and MRI
Evolution of BM Management
Stereotactic Radiosurgery (SRS)
Surgery
Patient Selection for SRS
Patient Immobilization
Simulation and Required Pretreatment Imaging
Pretreatment Imaging
Situations with MRI Contraindications
Target Delineation of BM (GTV, CTV)
Situation
De Novo BM
BM Involving Dura or Dural-Based BM
BM with Cystic or Hemorrhagic Component
Resection Cavity
PTV Margin
Dose Selection
Delineation of OAR
Complication and Mitigation Strategies
Use of Corticosteroids
Use of Anticonvulsants
Posterior Fossa Location
Area Postrema Location
Follow-Up
Areas of Uncertainty
Timing of Postoperative Cavity SRS
Preoperative Versus Postoperative SRS
Existing Guidelines
References
12: Indications for Whole-Brain Radiation Therapy
Case Vignette
Introduction
Patient Selection
Fractionation Schedules for WBRT
Postoperative Setting
Reirradiation Following WBRT
WBRT Salvage Following SRS
Leptomeningeal Disease
Prophylactic Cranial Irradiation
1–3 Brain Metastases – WBRT ± SRS
1–4 Brain Metastases – SRS ± WBRT
Future Directions – 4+ Brain Metastases
Impact of Systemic Therapies with CNS Activity
Neurotoxicity and HA-WBRT
References
13: Particle Therapy for the Treatment of Brain Metastases
Case Vignettes
Case 1
Case 2
Proton Basics
Dose Distribution
Scattering and Modulation
Biological Factors
Proton Stereotactic Radiosurgery Techniques
Immobilization and Image Guidance
Dosimetric Considerations
Proton Beam Dosimetry
Clinical Applications
Benign Intracranial Lesions
Proton SRS for Brain Metastases
Heavy Charged Particle SRS for Brain Metastases
Discussion
References
14: Special Topics in Brain Metastases Management
Osseous Skull Base Metastases
Case Vignette
Case 1
Introduction
Evidence Base
Diagnosis
Management
Radiation Therapy for Skull Base Metastases
Conventionally Fractionated Photon Radiation Therapy
Stereotactic Radiosurgery
Areas of Uncertainty
Conclusions and Recommendations
Choroidal Metastases
Case Vignette
Case 2
Introduction
Evidence Base
Diagnosis
Management
Radiation Therapy for Choroidal Metastases
Radiation Planning
Stereotactic Radiosurgery
Proton Radiation
Plaque Brachytherapy
Sequelae of Radiation Therapy
Areas of Uncertainty
Conclusions and Recommendations
Brainstem Metastases
Case Vignette
Case 3
Introduction
Evidence Base
Single-Fraction Stereotactic Radiosurgery
Hypofractionated Stereotactic Regimens
Future Directions
Conclusions and Recommendations
Dural-Based Metastases
Case Vignette
Case 4
Introduction
Evidence Base
Diagnosis
Management
Areas of Uncertainty
Conclusions and Recommendations
Leptomeningeal Disease
Case Vignette
Case 5
Introduction
Evidence Base
Diagnosis
Management
Future Directions
Conclusions and Recommendations
References
15: Salvage/Reirradiation/Retreatment
Case Vignettes
Case 1
Case 2
Case 3
Introduction
Evidence Base
Diagnosis of Recurrence
Treatment of New Metastases
Diagnosis and Management
Technical Aspects of Repeat SRS
Technical Aspects of Salvage WBRT
Areas of Uncertainty
Future Directions
Guidelines
NCCN (National Comprehensive Cancer Network)
AANS (American Association of Neurological Surgeons) [27]
ASCO (American Society of Clinical Oncology) [28]
EANO (European Association of Neuro-Oncology)
Conclusions and Recommendations
References
Part II: Technical: Treatment Planning and Delivery
16: General Techniques for Radiosurgery
Case Vignette
Technical Overview of Major Technologies
The Gamma Knife (GK) SRS System
CyberKnife (CK)
Linac
Evidence Base
Treatment Planning Considerations
GammaKnife
CyberKnife
Linac
Small Field Dosimetry
GammaKnife
CyberKnife
Linac
Targeting Accuracy
GammaKnife
CyberKnife
Linac
Areas of Uncertainty and Future Directions
GammaKnife
CyberKnife
Linac
Elements™
HyperArc™
New Concepts
MLCs
Guidelines
References
17: Single-Isocenter, Multiple Metastasis Treatment Planning
Background and History of Multiple Metastasis Treatment
Single-Isocenter Treatment of Multiple Metastases
Origins
Advantages of Single-Isocenter Treatment Planning
Potential Pitfalls of Single-Isocenter Planning
Island Blocking
Techniques in Single-Isocenter Multiple Metastasis Planning
IMRS
VMAT
Other VMAT Planning Considerations
Bridging
Limiting of Hotspots/Heterogeneity
Single-Isocenter Dynamic Conformal Arc
Automated Multiple Metastasis Treatment Planning Solutions
Multiple Metastasis Elements (MME)™
HyperArc
Comparison of Single-Isocenter Treatment Planning Solutions
Case Vignette
VMAT (RapidArc)
VMAT (HyperArc)
Appendix 17.1
References
18: Dose Tolerances in Brain Metastasis Management
Introduction
Evidence Base
Normal Tissue Dose Constraints of the Central Nervous System
Normal Brain Parenchyma
Brainstem
Optic Pathway and Other Skull Base Structures
Combined Systemic Therapies and Brain Irradiation
Reirradiation
Areas of Uncertainty
Conclusions and Recommendations
Case Vignettes
Case 1
Case 2
References
19: Evaluation of the Quality of a Radiosurgery Plan
Background
Dose-Volume Metrics
Conformity Indices
Shaw/RTOG
ICRU
Radiation Conformity Index or Undertreatment Ratio
Overtreatment Ratio or Selectivity Index or Healthy Tissues Conformity Index
Paddick CI/Conformation Number
New Conformity Index (NCI)/Nakamura’s CI
Geometric Conformity Index
COnformal INdex (COIN)
Gradient Indices
UF Gradient Index
Paddick/Dose Gradient Index
R50% or Falloff Index (FI)
Coverage
Minimum Coverage
Homogeneity
Homogeneity (RTOG)
Energy Index (Yomo)
Other Useful Indices
AUC-DVH
Efficiency Index
Twelve Gray Isodose Volume (V12Gy)
Case Vignettes
Organ Avoidance Is a Treatment Planning Goal
Case 1
Case 2
Authors’ Recommendations
References
20: Image Guidance for Frameless Radiosurgery Including Surface Mapping
Case Vignette
Case 1: A Patient Needs Both Single-Fraction and Hypofractionated Radiotherapy
Background and Motivation
Image-Guided Frameless Radiosurgery
Selecting Immobilization and Monitoring System
Description of a Frameless Image-Guided Radiosurgery Procedure
Geometric Uncertainties in Image-Guided Radiosurgery
OSI System Commissioning, Calibration, and QA
System Characterization and Commissioning
OSI Calibration Procedures
System QA and Annual Preventive Maintenance (PM)
X-Ray Imaging QA
Uncertainties in OSI Real-Time Motion Monitoring
Outer Structure from Planning CT
OSI Resolution and Frame Rate for Motion Monitoring
Staff Training and Credentialing
Recommendations and Future Directions
References
21: Safety Procedures and Checklists for Radiosurgery
Introduction
Concepts for Risk Mitigation
Safety Culture
Human Factors Engineering
Case Vignette – Case 1
Human Factors Engineering in the Selection of Incorrect Cone Size
Failure Modes and Effects Analysis
Case Vignette – Case 2
FMEA Analysis of Radiosurgery
Checklists and Checklist Design
Case Vignette – Case 3
Use of a Checklist to Mitigate Incorrect Laterality
Key Recommendations
Future Directions
References
22: Quality Assurance for Small Fields
Introduction
Relative Dosimetry
Percent Depth Dose and Beam Profiles
Detector Types
Ionization Chamber
Diode
Diamond
Plastic Scintillator
Radiochromic Film
Case Vignette – Case 1
Commissioning of Small Field Sizes for a Linear Accelerator
Treatment Planning System Commissioning and End-to-End Testing
Case Vignette – Case 2
End-to-End Testing of a VMAT SRS System
Patient-Specific Quality Assurance
Future Directions
References
23: Techniques of Whole Brain Radiation Therapy Including Hippocampal Avoidance
Case Vignettes
Case 1
Case 2
Case 3
Introduction
Rationale and Initial Experiences
Clinical Trials Evaluating WBRT
Evolution of Technique, Dose and Fractionation
Early Kilovoltage Era
2-Dimensional Treatment Planning Era
3-Dimensional Treatment Planning Era
Contemporary WBRT Practices
Treatment Planning, Dose and Fractionation
Tumor Histology
WBRT Plus SRS Boost
Post-operative WBRT
Repeat WBRT
Sparing of Organs at Risk
Hippocampus
Memantine
Parotids
Scalp Sparing
Areas of Uncertainty and Future Directions
Omitting WBRT
Role of Prophylactic Cranial Irradiation in Small Cell Lung Cancer
Reduction of Treatment-Related Sequelae
References
Index
