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ROSE CASE - FOR BRAIN MET CAVITY SRS

ROSE CASE - FOR BRAIN MET CAVITY SRS

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ROSE CASE - FOR BRAIN MET CAVITY SRS

  1. 1. ROSE CASE BRAIN METASTASIS CAVITY SRS RADIATION ONCOLOGY SIMULATION TO EXECUTION DR KANHU CHARAN PATRO
  2. 2. HISTORY • 47year male • Nonsmoker • ECOG-1 • One episode of GTCS in the month of march 12 2020. • Duration of the episode is for 3 to 4 min, followed by aura. • Post ictal confusion for a duration of 15 to 20 min • No headache and vomiting • No history of involuntary urination or defecation. • Another episode of GTCS in the month of June 15th 2020. • Duration of the episode is for 2 to 3 min, followed by aura. • Post ictal confusion for a duration of 25 to 30 min • No headache and vomiting’s. • No history of involuntary urination or defecation
  3. 3. • Left occipital lobe and inferior temporal lobe. • Lesion of size 3.2*3.2 cm • Hypointense on T1 . • Heterogenous on T2 . • Brilliantly heterogenous enhancement • Perilesional edema present • Occipital horn of left lateral ventricle dilated. • MR spectroscopy shows increased choline and decreased NAA. • Possibilities :? Ganglioglioma PRE OP MRI
  4. 4. Preop image MRI Adjacent to dura Sinus involvement
  5. 5. • Left Prieto occipital craniotomy • Gross total excision • Very vascular • Clear plane of cleavage SURGERY
  6. 6. • pT- 4cm x 3.5cm x 1.5cm • Metastatic papillary Adeno carcinoma • CK7 positive • TTF1 positive • ALK- Awaited • ROS- Awaited • EGFR- Awaited Histopathology and IHC
  7. 7. • Left temporo-occipital region lesion • Post surgical defect of size 3.2*3.0cm • Thick walled minimal irregular outline cavity • Central cystic • Hypointense on T1 • Hyperintense on T2 • Bloom on wall cavity s/o hemorrhagic products • No perilesional edema is seen. • Hyperintense on diffusion images along the peripheral wall of lesion. POST OP MRI
  8. 8. • Brain : surgical defect in the left parieto-occipital region • Size 3.2*2.4cm • Lung : spiculated lesion in the upper lobe of right lung . • Size 2.6*2.1 (SUV max 3.5) • Innumerable sub centimeter nodules in both the lungs. s/o met • Right paratracheal lymph node size 1.1*1.6 (SUV max 3). • Hypermetabolic lymph nodes in the right paratracheal and subcarinal region. PET SCAN WHOLE BODY
  9. 9. • CA Right lung with brain metastasis • Post operative case of the brain metastasis • TNM staging : cT4N2M1b Final Diagnosis
  10. 10. Tumor board decision • After group discussion with neurosurgeon, radiation oncologist and medical oncologist board decided to plan for stereotactic radiotherapy followed by chemotherapy • Patient was explained about complications and outcome of the procedure
  11. 11. STEREOTACTIC RADIOSURGERY FOLLOWED BY CHEMOTHERAPY PLAN of treatment
  12. 12. Patient discussion • Discussed about the procedure • Discussed about imaging and follow up • Discussed about tumor response • Discussed about need of radiotherapy in future[WBRT/SRS] • Discussed about post radiotherapy raised ICT
  13. 13. TUMOR CONTROL APPERANCE OF NEW LESION IN FUTURE RADIONECROSIS Patient discussion
  14. 14. • Planned for FSRT • Plan multiple fraction • 30Gy/5# - marginal dose Radiation tumor board
  15. 15. Immobilization and set up
  16. 16. Time interval to address cavity dynamics Caution must be taken when treating cavities in the early(<21 days) interval after surgery as it may lead to irradiating more normal tissue especially in small tumors
  17. 17. Time interval to address cavity dynamics
  18. 18. Give adequate DREAM protocol before planning image to decrease edema Drug Dosage D Inj. /tab DEXA 8mg Thrice a day after food 5days R Inj. /tab Ranitidine Twice a day before food 5days E Inj. /tab Emset 8mg Thrice a day before food 5days A ANTIEPILEPTICS SOS M Inj. Mannitol Syp. Glycerol Thrice a day infusion over 20 min 20 ml Thrice a day in apple juice
  19. 19. • Surgery date -23rd JUNE 2020 • MRI planning 17th JULY 2020 - 24th day post op • CT planning – 21st JULY 2020 - 28th day post op Time interval to address cavity dynamics
  20. 20. • 1mm slice • Contrast • Vertex to neck • With Fraxion • CT plan done at end of 28th day of surgery keeping the cavity remodeling in mind Planning CT
  21. 21. MRI protocol • T1/T2/FLAIR sequence- Usual sequence • 3D FSPGR contrast- Normal anatomy • 512x 512 matrix • 1mm slice • No gap • No tilt • Neutral neck • FOV should include • body contour nose, eye and skull
  22. 22. Pattern of recurrence in cavity • Cavity • LMD-leptomeningeal spread – Nodular pattern – Sugarcoat pattern • Surgical tract • Based on histology
  23. 23. • Breast cancer histology, • Piecemeal resection of BM • Posterior fossa location • Multiple BM • And hemorrhagic or cystic features • It is thought that this increased risk is due to tumor spillage into the cerebrospinal fluid (CSF) at the time of surgical resection Risk factors for LMD
  24. 24. • Nodular LMD (nLMD) was defined as new focal extra-axial distinct nodular enhancing lesions located on the leptomeninges or ependyma. • Classical LMD (cLMD) was akin to “sugarcoating” enhancement and was defined as new linear or curvilinear enhancement of the leptomeninges involving the sulci of the cerebral hemispheres, cranial nerves, brainstem, cerebellar folia, or ependyma Types of recurrence
  25. 25. Consensus guidelines
  26. 26. Basics of target delineation • ADJACENT DURA and SURGICAL TRACT • BONE FLAP INNER PART • CAVITY PROPER • DURAL SINUS • ENHANCING COMPONENT
  27. 27. A-Contour of Adjacent Dura
  28. 28. B-Contour of Bony flap and tract
  29. 29. C-Contour of Cavity
  30. 30. D-Contour of Dural sinus
  31. 31. E-Contour of Enhancing component
  32. 32. • A+B+C+D+E • CTV delineation • VOLUME- cc • Multiplanar evaluation Target delineation total CTV
  33. 33. • 1mm • VOLUME-37.491CC PTV
  34. 34. • VOLUME- 1598CC Brain-CTV
  35. 35. Multiplanar CTV and PTV
  36. 36. Smooth your contour
  37. 37. OAR DELINEATIONOAR delineation
  38. 38. Image fusion
  39. 39. • VMAT • DCARC • 3DCRT • IMRT Planning
  40. 40. The dose selection
  41. 41. The dose selection
  42. 42. Wait for Alliance A071801 trial
  43. 43. SL NO PARAMETER VALUE 1 D MAX 36.43Gy 2 D95% 31.01Gy 3 D100% 28.23Gy 4 V95% 99.99% 5 V30 Gy[V100%] 99.56% 6 V110% 44.45% 7 V120% 0.03% 8 V130% 0% 1. Prescription Isodose level is usually not 100% PD covering 100% PTV 2. Often 95% PD covering 95% PTV or higher 3. Or 100% PD covering 95% PTV or higher. Michael Torrens,/J Neurosurg (Suppl 2)/2014 PTV coverage index
  44. 44. • FORMULA • VOLUME OF PRESCRIPTION ISODOSE/PTV VOLUME • 43.798/37.491=1.17 • DESIRABLE=1 [Sonja Petkovska Proceedings of the Second Conference on Medical Physics and Biomedical Engineering] RTOG conformity index
  45. 45. • FORMULA (VOLUME OF PRESCRIPTION ISODOSE IN AREA OF INTEREST)2 PTV VOLUME X VOLUME OF PRESCRIPTION ISODOSE • =39.764 x 39.764 /37.494 x43.798 =0.96 • IDEAL= > 0.85. AND <1 Michael Torrens,/J Neurosurg (Suppl 2)/2014 Paddick conformity index
  46. 46. • FORMULA • MAXIMUM DOSE/PRESCRIPTION DOSE • 36.43Gy/30Gy=1.21 • DESIRABLE = 1.1-1.3 HOMOGENITY index
  47. 47. • Dose fall off observation is very much needed in this evaluation under headings • Gradient index • Difference between various isodose lines • e.g between 80% and 60%- ideal- <2mm • Between 80% and 40%- ideal- < 8mm • For that reason we have to calculate equivalent radius Dose fall off
  48. 48. • To evaluate dose gradient we have to find out difference between radius of various isodose line • But none is iso spherical • We have to find out equivalent radius from formula • First find out the specified isodose volume • Then calculate the radius • V=4/3 πr3 • r= (3V/4π)1/3 Equivalent radius
  49. 49. SL NO PARAMETER VOLUME RADIUS 1 100% ISODOSE 43.79CC 2.19mm 2 80% ISODOSE 64.45CC 2.49mm 3 60% ISODOSE 101.19CC 2.89mm 4 50% ISODOSE 130.84CC 3.15mm 5 40% ISODOSE 177.96CC 3.49mm r= (3V/4π)1/3 Equivalent radius
  50. 50. • FORMULA – Difference of equivalent radius of prescription isodose and equivalent radius of 50% isodose • 2.19mm-3.15mm=0.96mm • It should be between 0.3 to 0.9 Gradient index
  51. 51. • BETWEEN 80% AND 60%- IDEAL-<2mm – HERE- 0. 4mm • BETWEEN 80% AND 40%- IDEAL- <8mm – HERE- 1mm EORTC-22952-26001 Distance between various isodose lines
  52. 52. BMC - BRAIN MINUS CAVITY
  53. 53. • Requirement V30Gy = 10.5cc • Achieved =10.30cc BMC - BRAIN MINUS CAVITY Salman Faruqi/ IJROBP/ 2019
  54. 54. BMC - BRAIN MINUS CAVITY
  55. 55. Isodose line COLOUR ISODOSE LINE Dark green 100% Light green 80% Sky green 60% Pink 50% Blue 40% ISODOSE LINES
  56. 56. CONSTRAINTS
  57. 57. SL NO ORGAN DESIRABLE ACHIEVED 1 RT. EYE MAX <22.5Gy 1.97Gy 2 LT. EYE MAX <22.5Gy 4.4Gy 3 RT. OPTIC NERVE MAX <22.5Gy 2.3Gy 4 LT. OPTIC NERVE MAX <22.5Gy 5.5Gy 5 OPTIC CHIASM MAX <22.5Gy 7.5Gy 8 BRAIN STEM MAX 23-31Gy 10.01Gy 9 RT. COCHLEA MEAN <25Gy <1Gy 10 LT. COCHLEA MEAN <25Gy <1Gy GG HANNA/CLINICAL ONCOLOGY/2016 OAR coverage
  58. 58. • MECHANICAL ISOCENTER CHECK – WINSTON LUTZ TEST • POINT DOSE VERIFICATION • TOLERANCE-1MM Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015 QA part
  59. 59. Dry run
  60. 60. • CBCT CORRECTIONS Set-up verification
  61. 61. • HEXAPOD CORRECTIONS Set-up verification
  62. 62. PREMEDICATION • TAB. DEXAMETHASONE 8MG THRICE DAILY STARTING DAY BEFORE • TAB. ONDANSETRON 8MG THRICE DAILY STARTING DAY BEFORE • TAB. PAN 4O ONCE DAILY STARTING DAY BEFORE • DIABETES CARE IF Pre medication-optional
  63. 63. • TAPER THE STEROID OVER A WEEK • ANTI EMETICS • PPI Post medication-optional
  64. 64. • Imaging after 3 months Advised
  65. 65. DOCTORS • DR P S BHATTACHARYA • DR C R KUNDU • DR V K REDDY • DR P MADHURI PHYSICISTS • MR A C PRABU • MR A SRINU • MR Prasad • DR ANIL KUMAR TECHNOLOGIST TEAM Acknowledgments

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