Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.
ROSE CASE
STEREOTAXY FOR MENINGIOMA
RADIATION ONCOLOGY
SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO
4/24/2021 1
4/24/2021 2
CASE DETAILS FOR SRS
History
• 41 years old female presented with history of headache for 4
months which was intermittent severe stabbing type ...
4/24/2021 4
4/24/2021 5
• 2.2 × 1.9 × 2.3cm
• Well defined, intensely enhancing, extraaxial
• T2W hypointense, T1 isointense
• Posterior to left c...
4/24/2021 7
imaging finding
Sx
• Near total excision
• By Kawase approach
4/24/2021 8
Histological Examination
• 3x3x1cm
• Firm, whorled and myxoid
• Spindle shaped tumor cells in fascicles, whorls with
inter...
Hearing and vision
• Bilateral vision normal
• Bilateral hearing normal
4/24/2021 10
Final Diagnosis
4/24/2021 11
Petro clival meningioma left
side with trigeminal pain and
facial palsy-residual lesion
• NEUROSURGEON
• RADIATION ONCOLOGIST
MULTI DISCIPLINARY DISCUSSION
4/24/2021 12
Tumor board decision
• After group discussion with neurosurgeon,
radiation oncologist board decided to plan for
stereotact...
STEREOTACTIC RADIOSURGERY
PLAN of treatment
4/24/2021 14
Patient discussion
• Discussed about the procedure
• Discussed about imaging and follow up
• Discussed about response rate...
Simulation
4/24/2021 16
MRI protocol
• T1/T2/FLAIR sequence- Usual sequence
• 3D FSPGR contrast- Normal anatomy
• 512x 512 matrix
• 1mm slice
• No...
• 1mm slice
• Contrast
• Vertex to neck
• With SRS mask
• CT contrast
Planning CT
4/24/2021 18
MULTIPLANNAR CT – MR FUSION
Imaging
• The time interval between imaging and treatment delivery should be as short as possible
• For planning purposes,...
Delineating the target
• The GTVis defined as the visible lesion on MRI; typically, this is the contrast-
enhancing lesion...
Delineating the target
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
Delineating the target summary
• See T1contrast enhancement area
• See T2 for cavernous sinus involvement
– Sinus is black...
INCLUDE ONLY THICKENED DURAL TAIL
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
INCLUDE HYPEROSTOSIS IN CT BONE WINDOW
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
Delineating OAR
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
CRANIAL NERVE DOSE IN CAVERNOUS SINUS
1. For single fractions delivering a maximum dose to the cavernous sinus of up to
40...
Is SRS for cavernous sinus meningioma[CSM] is safe?
Stereotactic Radiosurgery and fractionated Stereotactic Radiotherapy w...
Is SRS for cavernous sinus meningioma is safe?
No relationship of dose
to cavernous sinus and
neuropathy in CN III-VI
(ran...
Is SRS for cavernous sinus meningioma is safe?
Correa et al. Radiation Oncology
2014
OAR CONSTRAINTS AND TOXICITY RATE
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
Pituitary and pituitary stalk dose in SRS
Minniti et al. Radiation Oncology (2016)
Hippocampus dose in SRS
Isabella Zhang/Practical Radiation Oncology (2017)
GTV
1. VOLUME-1.640CC
PTV
1. 2mm VOLUME-5.875CC
2. 1MM VOLUME-3.738CC
4/24/2021 35
Smooth your contour-PTV
4/24/2021 36
[PTV – OC] DISTANCE
4/24/2021 37
OAR
Brain-PTV
4/24/2021 39
DELINEATING 5th NERVE
Dose selection
1.Target definition using volume MRI or T1W Gd
enhanced
2.Typically 12 – 16 Gy to the margin of the lesion
...
DOSE SELECTION
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
OAR
F. Meniai-Merzouki./scientific reports /2018
Dose selection
Dose selection
Dose selection
Dose selection
Dose selection
Dose selection
Dose selection
Dose selection
Dose selection
The long-term outcome suggests that fractionated stereotactic radiotherapy is a safe
and effective treatmen...
Dose selection
Dose selection
In cases where a history of prior irradiation and/or inability to meet constraints for OARs
complicate trea...
University hospital of wales protocol
Dose selection
EXTRAPOLATION
4/24/2021 56
ISRS RECOMMENDATION
Final decision on dose selection on tumor board
1. Radio necrosis is less with fractionated SRS
2. Edema is less with frac...
• VMAT
• D-ARC
• 3DCRT
• IMRT
Planning
4/24/2021 58
SL NO PARAMETER VALUE
1 D MAX 32.03Gy
2 D95% 25.40Gy
3 D100% 22.72Gy
4 V95% 99.7%
5 V25Gy[V100%] 97.06%
6 V27.5[110%] 72.1...
• FORMULA
• VOLUME OF PRESCRIPTION ISODOSE/PTV VOLUME
• 7.407/5.875=1.26
• DESIRABLE=1
[Sonja Petkovska
Proceedings of the...
• FORMULA
(VOLUME OF PRESCRIPTION ISODOSE IN AREA OF INTEREST)2
PTV VOLUME X VOLUME OF PRESCRIPTION ISODOSE
• 6.304 x 6.30...
• FORMULA
• MAXIMUM DOSE/PRESCRIPTION DOSE
• 32.03/25Gy=1.28
• DESIRABLE = 1.1-1.3
HOMOGENITY index
4/24/2021 62
• Dose fall off observation is very much needed in this
evaluation under headings
• Gradient index
• Difference between va...
• To evaluate dose gradient we have to find out
difference between radius of various isodose line
• But none is iso spheri...
SL NO PARAMETER VOLUME RADIUS
1 100% ISODOSE 7.407cc 1.21mm
2 80% ISODOSE 14.121CC 1.5mm
3 60% ISODOSE 23.812CC 1.7mm
4 50...
• FORMULA
– Difference of equivalent radius of prescription
isodose and equivalent radius of 50% isodose
• 1.96 mm-1.21mm=...
• BETWEEN 80% AND 60%- IDEAL-<2mm
– HERE- 1.78-1.5=0.28mm
• BETWEEN 80% AND 40%- IDEAL- <8mm
– HERE- 2.2- 1.5 =0. 7mm
EORT...
BMC - BRAIN MINUS CAVITY
• Requirement V27Gy = 10.5cc
• Achieved =10cc= 16.23cc
BMC - BRAIN MINUS CAVITY
Salman Faruqi/ IJROBP/ 2019
CONSTRAINTS
4/24/2021 70
Pituitary and pituitary stalk dose in SRS
Minniti et al. Radiation Oncology (2016)
Hippocampus dose in SRS
Isabella Zhang/Practical Radiation Oncology (2017)
NO ORGAN 1# 3# 5# ACHIEVED REFERENCE
1 RT. EYE MAX <8Gy MAX <15Gy MAX <22.5Gy 2.6 Gy Gg Hanna/Clinical Oncology/2016
2 LT....
DVH
DVH STATISTICS-1
DVH STATISTICS-2
BEAM
ARRANGEMENTS
BEAM ARRANGEMENTS
ISODOSE LINES
COLOUR ISODOSE LINE
Green PTV
Red 100%
orange 80%
Yellow 60%
pink 50%
Blue 40%
4/24/2021 79
• MECHANICAL ISOCENTER CHECK
– WINSTON LUTZ TEST
• POINT DOSE VERIFICATION
• TOLERANCE-1MM
Travis R. Denton/JOURNAL OF APP...
Dry run
4/24/2021 81
• CBCT CORRECTIONS
Set-up verification-CBCT
4/24/2021 82
• HEXAPOD CORRECTIONS
Set-up verification- HEXAPOD
4/24/2021 83
PREMEDICATION
• Tab. Dexamethasone 8mg thrice daily starting day
before
• Tab. Ondansetron 8mg thrice daily starting day
b...
FOLLOW UP PROTOCOL
Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
• All of the patients were followed prospectively aft...
RESPONSE EVALUATION
Sebastião Francisco Miranda Correa/radiation oncology/2014
• Progression free survival was determined ...
RESPONSE EVALUATION-RANO CRITERIA
Huang et al./Neuro-Oncology/2018
• Imaging after 6 months
Advised
4/24/2021 88
DOCTORS
• Dr T Suresh
• Dr P S Bhattacharya
• Dr C R Kundu
• Dr V K Reddy
• Dr Sajal Kakkar
• Dr Deepak Gupta
• Dr M Mruty...
Próxima SlideShare
Cargando en…5
×

ROSE CASE - SRS/ STEREOTACTIC RADIOTHERAPY FOR MENINGIOAMA

ROSE CASE - SRS/ STEREOTACTIC RADIOTHERAPY FOR MENINGIOAMA

  • Sé el primero en comentar

ROSE CASE - SRS/ STEREOTACTIC RADIOTHERAPY FOR MENINGIOAMA

  1. 1. ROSE CASE STEREOTAXY FOR MENINGIOMA RADIATION ONCOLOGY SIMULATION TO EXECUTION DR KANHU CHARAN PATRO 4/24/2021 1
  2. 2. 4/24/2021 2 CASE DETAILS FOR SRS
  3. 3. History • 41 years old female presented with history of headache for 4 months which was intermittent severe stabbing type of pain along the distribution of the branches of LT trigeminal nerve(V) all three divison • H/o pain left eye • No h/o vomiting, Head reeling sensation, blurring of vision • No h/o limb weakness , seizure episodes • No co morbidities 4/24/2021 3
  4. 4. 4/24/2021 4
  5. 5. 4/24/2021 5
  6. 6. • 2.2 × 1.9 × 2.3cm • Well defined, intensely enhancing, extraaxial • T2W hypointense, T1 isointense • Posterior to left cavernous sinus • Indenting on pons • Probable invasion of meckele‘s cave and 5th nerve on left side 4/24/2021 6 imaging finding
  7. 7. 4/24/2021 7 imaging finding
  8. 8. Sx • Near total excision • By Kawase approach 4/24/2021 8
  9. 9. Histological Examination • 3x3x1cm • Firm, whorled and myxoid • Spindle shaped tumor cells in fascicles, whorls with intersecting psammoma bodies • Grade 1 transitional meningioma 4/24/2021 9
  10. 10. Hearing and vision • Bilateral vision normal • Bilateral hearing normal 4/24/2021 10
  11. 11. Final Diagnosis 4/24/2021 11 Petro clival meningioma left side with trigeminal pain and facial palsy-residual lesion
  12. 12. • NEUROSURGEON • RADIATION ONCOLOGIST MULTI DISCIPLINARY DISCUSSION 4/24/2021 12
  13. 13. Tumor board decision • After group discussion with neurosurgeon, radiation oncologist board decided to plan for stereotactic radiotherapy • Patient was explained about complications and outcome of the procedure 4/24/2021 13
  14. 14. STEREOTACTIC RADIOSURGERY PLAN of treatment 4/24/2021 14
  15. 15. Patient discussion • Discussed about the procedure • Discussed about imaging and follow up • Discussed about response rate • Discussed about the complications • Discussed about the repeat SRS • Discussed about post radiotherapy raised ICT • How it works? • How will be the follow up • Complication and rates? 4/24/2021 15
  16. 16. Simulation 4/24/2021 16
  17. 17. 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 • DOTA scan 4/24/2021 17
  18. 18. • 1mm slice • Contrast • Vertex to neck • With SRS mask • CT contrast Planning CT 4/24/2021 18
  19. 19. MULTIPLANNAR CT – MR FUSION
  20. 20. Imaging • The time interval between imaging and treatment delivery should be as short as possible • For planning purposes, MRI scans are subsequently fused with thin-slice non-contrast enhanced CT scans. • Of note, CT scans may have a complimentary role in the imaging of skull base, specifically showing the pattern of bone involvement, e.g. hyperostosis and osteolysis, as well identifying intratumoral calcification better than MRI • A contrast enhanced CT is usually recommended only if MRI cannot be performed • Contrast-enhanced 3D fast gradient echo T1-weighted sequences obtained with a voxel size of 1 x1x 1 mm, named MPRAGE, 3D FLASH, 3D FGRE, 3D FSPGR, 3D TFE, 3D FFE depending on the manufacturer, should be recommended for their high spatial resolution and accurate characterization of subtle enhancement patterns in the surrounding neurovascular structures, and along the course of the optic nerves • PET imaging mainly with DOTATOC- or DOTANOC-tracers has shown to improve target volume definition, e.g. patients with large tumors infiltrating the parapharyngeal soft tissues or for those located in the bony structures which are difficult to be distinguished on MRI and CT • In addition, extra-axial growth can be verified on T2-weighted images by cerebrospinal fluid (CSF) cleft interposed between the tumor and the parenchyma. • CT is valuable for the detection of calcification of varying degrees within the tumor and hyperostosis of adjacent boneIn addition, extra-axial growth can be verified on T2-weighted images by cerebrospinal fluid (CSF) cleft interposed between the tumor and the parenchyma. • CT is valuable for the detection of calcification of varying degrees within the tumor and hyperostosis of adjacent bone Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  21. 21. Delineating the target • The GTVis defined as the visible lesion on MRI; typically, this is the contrast- enhancing lesion. • The clinical target volume (CTV) is defined as the volume of tissue that contains the GTV and any microscopic disease and potential paths of microscopic spread. • In general, additional margin expansion from GTV to CTV is unnecessary for benign skull base tumors; • However, a small margin of 1–3 mm may be added to encompass potential areas of microscopic tumor infiltration, e.g the intracavernous portion of rapidly growing lesions. • For specific histologies, such asatypical and malignant meningiomas or chordomas, large CTV margins in the range of 10–20 mm are frequently utilized to adequately cover the microscopic extent of disease, that may be reduced around natural barriers to tumor growth such as the skull • A margin of 1–2 mm is generally used for GTV-to-PTV expansion in patients receiving frameless SRS, Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  22. 22. Delineating the target Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  23. 23. Delineating the target summary • See T1contrast enhancement area • See T2 for cavernous sinus involvement – Sinus is black on T2[easy to differentiate] – Sinus will enhance on T1contrast[difficult to differentiate] • CT is valuable for the detection of calcification of varying degrees within the tumor and hyperostosis of adjacent bone. • PET imaging mainly with DOTATOC- or DOTANOC-tracers has shown to improve target volume definition, e.g. patients with large tumors infiltrating the parapharyngeal soft tissues or for those located in the bony structures which are difficult to be distinguished on MRI and CT Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  24. 24. INCLUDE ONLY THICKENED DURAL TAIL Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  25. 25. INCLUDE HYPEROSTOSIS IN CT BONE WINDOW Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  26. 26. Delineating OAR Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  27. 27. CRANIAL NERVE DOSE IN CAVERNOUS SINUS 1. For single fractions delivering a maximum dose to the cavernous sinus of up to 40Gy, there were relatively few severe complications observed. 2. No definite relationship was observed between the maximum dose to cavernous sinus and subsequent complications involving cranial nerves III-VI ROY B. TISHLER/IJROBP/1993
  28. 28. Is SRS for cavernous sinus meningioma[CSM] is safe? Stereotactic Radiosurgery and fractionated Stereotactic Radiotherapy were equally safe and effective in the management of symptomatic CSMs Correa et al. Radiation Oncology 2014
  29. 29. Is SRS for cavernous sinus meningioma is safe? No relationship of dose to cavernous sinus and neuropathy in CN III-VI (range 5-40 Gy)
  30. 30. Is SRS for cavernous sinus meningioma is safe? Correa et al. Radiation Oncology 2014
  31. 31. OAR CONSTRAINTS AND TOXICITY RATE Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  32. 32. Pituitary and pituitary stalk dose in SRS Minniti et al. Radiation Oncology (2016)
  33. 33. Hippocampus dose in SRS Isabella Zhang/Practical Radiation Oncology (2017)
  34. 34. GTV 1. VOLUME-1.640CC
  35. 35. PTV 1. 2mm VOLUME-5.875CC 2. 1MM VOLUME-3.738CC 4/24/2021 35
  36. 36. Smooth your contour-PTV 4/24/2021 36
  37. 37. [PTV – OC] DISTANCE 4/24/2021 37
  38. 38. OAR
  39. 39. Brain-PTV 4/24/2021 39
  40. 40. DELINEATING 5th NERVE
  41. 41. Dose selection 1.Target definition using volume MRI or T1W Gd enhanced 2.Typically 12 – 16 Gy to the margin of the lesion 3.Located at least 3-5 mm from optic nerve or chiasm (preferably 5 mm) 4.Fractionated schedules 1.larger lesions 2.impinging on the optic apparatus 3.< 1cm Parasagital/parafalcine location
  42. 42. DOSE SELECTION Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021
  43. 43. OAR F. Meniai-Merzouki./scientific reports /2018
  44. 44. Dose selection
  45. 45. Dose selection
  46. 46. Dose selection
  47. 47. Dose selection
  48. 48. Dose selection
  49. 49. Dose selection
  50. 50. Dose selection
  51. 51. Dose selection
  52. 52. Dose selection The long-term outcome suggests that fractionated stereotactic radiotherapy is a safe and effective treatment for intracranial skull base benign meningioma, especially for those who have tumors ,9.1 cc or would receive fractionated stereotactic radiotherapy with or without surgery as the initial treatment.
  53. 53. Dose selection
  54. 54. Dose selection In cases where a history of prior irradiation and/or inability to meet constraints for OARs complicate treatment planning with SRS, fSRS can be considered. Longer follow up of our cohort will be needed to ensure that the LC and toxicity rates are durable
  55. 55. University hospital of wales protocol Dose selection EXTRAPOLATION
  56. 56. 4/24/2021 56 ISRS RECOMMENDATION
  57. 57. Final decision on dose selection on tumor board 1. Radio necrosis is less with fractionated SRS 2. Edema is less with fractionated SRS 3. Better/ equal tumor control with fractionated SRS 4. Cranial nerve symptoms are better with fractionated SRS 5. Lesions located near vital structures are better with fractionated SRS 6. So, we planed for 25Gy/5#
  58. 58. • VMAT • D-ARC • 3DCRT • IMRT Planning 4/24/2021 58
  59. 59. SL NO PARAMETER VALUE 1 D MAX 32.03Gy 2 D95% 25.40Gy 3 D100% 22.72Gy 4 V95% 99.7% 5 V25Gy[V100%] 97.06% 6 V27.5[110%] 72.15% 7 V30Gy [120%] 17.38% 8 V130% 0% 9 Dmean 28.38Gy 10 Dmin 22.72Gy 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 4/24/2021 59
  60. 60. • FORMULA • VOLUME OF PRESCRIPTION ISODOSE/PTV VOLUME • 7.407/5.875=1.26 • DESIRABLE=1 [Sonja Petkovska Proceedings of the Second Conference on Medical Physics and Biomedical Engineering] RTOG conformity index 4/24/2021 60
  61. 61. • FORMULA (VOLUME OF PRESCRIPTION ISODOSE IN AREA OF INTEREST)2 PTV VOLUME X VOLUME OF PRESCRIPTION ISODOSE • 6.304 x 6.304/5.875 x 7.407 • Here 0.913 • IDEAL= > 0.85. AND <1 Michael Torrens,/J Neurosurg (Suppl 2)/2014 Paddick conformity index 4/24/2021 61
  62. 62. • FORMULA • MAXIMUM DOSE/PRESCRIPTION DOSE • 32.03/25Gy=1.28 • DESIRABLE = 1.1-1.3 HOMOGENITY index 4/24/2021 62
  63. 63. • 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 4/24/2021 63
  64. 64. • 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 4/24/2021 64
  65. 65. SL NO PARAMETER VOLUME RADIUS 1 100% ISODOSE 7.407cc 1.21mm 2 80% ISODOSE 14.121CC 1.5mm 3 60% ISODOSE 23.812CC 1.7mm 4 50% ISODOSE 31.63CC 1.96mm 5 40% ISODOSE 44.395CC 2.2mm r= (3V/4π)1/3 Equivalent radius 4/24/2021 65
  66. 66. • FORMULA – Difference of equivalent radius of prescription isodose and equivalent radius of 50% isodose • 1.96 mm-1.21mm=0.75 mm • It should be between 0.3 to 0.9 Gradient index 4/24/2021 66
  67. 67. • BETWEEN 80% AND 60%- IDEAL-<2mm – HERE- 1.78-1.5=0.28mm • BETWEEN 80% AND 40%- IDEAL- <8mm – HERE- 2.2- 1.5 =0. 7mm EORTC-22952-26001 Distance between various isodose lines 4/24/2021 67
  68. 68. BMC - BRAIN MINUS CAVITY
  69. 69. • Requirement V27Gy = 10.5cc • Achieved =10cc= 16.23cc BMC - BRAIN MINUS CAVITY Salman Faruqi/ IJROBP/ 2019
  70. 70. CONSTRAINTS 4/24/2021 70
  71. 71. Pituitary and pituitary stalk dose in SRS Minniti et al. Radiation Oncology (2016)
  72. 72. Hippocampus dose in SRS Isabella Zhang/Practical Radiation Oncology (2017)
  73. 73. NO ORGAN 1# 3# 5# ACHIEVED REFERENCE 1 RT. EYE MAX <8Gy MAX <15Gy MAX <22.5Gy 2.6 Gy Gg Hanna/Clinical Oncology/2016 2 LT. EYE MAX <8Gy MAX <15Gy MAX <22.5Gy 2.87Gy Gg Hanna/Clinical Oncology/2016 9 RT. LENS MAX <1.5Gy MAX <5Gy MAX <7Gy 1.8Gy F. Meniai-Merzouki./scientific reports /2018 10 LT. LENS MAX <1.5Gy MAX <5Gy MAX <7Gy 1.92Gy F. Meniai-Merzouki./scientific reports /2018 3 RT. OPTIC NERVE MAX <8Gy MAX <15Gy MAX <22.5Gy 4.34Gy Gg Hanna/Clinical Oncology/2016 4 LT. OPTIC NERVE MAX <8Gy MAX <15Gy MAX <22.5Gy 8.5Gy Gg Hanna/Clinical Oncology/2016 5 OPTIC CHIASM MAX <8Gy MAX <15Gy MAX <22.5Gy 16.09Gy Gg Hanna/Clinical Oncology/2016 6 BRAIN STEM MAX <15Gy MAX <23Gy MAX <31Gy 25.29Gy Gg Hanna/Clinical Oncology/2016 7 RT. COCHLEA Mean <9Gy Mean <17Gy Mean <25Gy 2.95Gy Gg Hanna/Clinical Oncology/2016 8 LT. COCHLEA Mean <9Gy Mean <17Gy Mean <25Gy 14.05Gy Gg Hanna/Clinical Oncology/2016 11 RT.HIPPO MAX <6.6 Gy D40<4.5Gy 6.1Gy Isabella Zhang/Practical Radiation Oncology /2017 12 LT. HIPPO MAX <6.6 Gy D40<4.5Gy 21.08Gy Isabella Zhang/Practical Radiation Oncology /2017 13 PITUITARY Mean <15Gy 17.88Gy Minniti et.al/Radiation Oncology /2017 Stephanie et al/radiotherapy and oncology/2021 14 PITUITARY STLAK Mean <7Gy 17.62Gy 15 PBRAIN-PTV-D10CC 12Gy 30Gy JOHN C. FLICKINGER/IJROBP/2000 Salman faruqi/IJROBP/2019 16 RT. CAVERNOUS SINUS 17 LT. CAVERNOUS SINUS 18 CRANIAL NERVES 12.5-15 Gy Hasegawa Neurosurgery 2005 Flickenger IJROBP 2004 OAR coverage 73
  74. 74. DVH
  75. 75. DVH STATISTICS-1
  76. 76. DVH STATISTICS-2
  77. 77. BEAM ARRANGEMENTS BEAM ARRANGEMENTS
  78. 78. ISODOSE LINES COLOUR ISODOSE LINE Green PTV Red 100% orange 80% Yellow 60% pink 50% Blue 40%
  79. 79. 4/24/2021 79
  80. 80. • MECHANICAL ISOCENTER CHECK – WINSTON LUTZ TEST • POINT DOSE VERIFICATION • TOLERANCE-1MM Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015 QA part 4/24/2021 80
  81. 81. Dry run 4/24/2021 81
  82. 82. • CBCT CORRECTIONS Set-up verification-CBCT 4/24/2021 82
  83. 83. • HEXAPOD CORRECTIONS Set-up verification- HEXAPOD 4/24/2021 83
  84. 84. PREMEDICATION • Tab. Dexamethasone 8mg thrice daily starting day before • Tab. Ondansetron 8mg thrice daily starting day before • Tab. Pan 40 once daily starting day before • Antiepileptic for 6-8 weeks • Diabetes care if • Taper the steroid over 3 weeks • Anti emetics • PROTON PUMP INHIBITOR Peri medication 4/24/2021 84
  85. 85. FOLLOW UP PROTOCOL Stephanie E. Combs/RADIOTHERAPY AND ONCOLOGY/2021 • All of the patients were followed prospectively after the treatment. • The protocol included medical evaluations for neurological symptoms and cranial MRI. • A first follow-up visit was scheduled 40 days after completion of radiation, and at 3 month intervals thereafter for the first year. • From the second year on, follow-up intervals were extended to 6-12 month intervals or as requested clinically. • At least 3 years of follow-up was required. • Progression free survival was determined based on the RECIST criteria that evaluate two orthogonal diameters of the tumour. • Radiological response was defined as the disappearance of the enhancement of the tumour mass or shrinkage of initial volume by at least 20 mm on MRI. • Clinical response was defined as regression in signs or symptoms of up to 80% based on pre-treatment levels.
  86. 86. RESPONSE EVALUATION Sebastião Francisco Miranda Correa/radiation oncology/2014 • Progression free survival was determined based on the RECIST criteria that evaluate two orthogonal diameters of the tumour. • Radiological response was defined as the disappearance of the enhancement of the tumour mass or shrinkage of initial volume by at least 20 mm on MRI. • Clinical response was defined as regression in signs or symptoms of up to 80% based on pre-treatment levels. • Evaluate the calcification intensity • SRS may result in decreased volumes of the soft tissue component, and the calcified portion of the tumour
  87. 87. RESPONSE EVALUATION-RANO CRITERIA Huang et al./Neuro-Oncology/2018
  88. 88. • Imaging after 6 months Advised 4/24/2021 88
  89. 89. DOCTORS • Dr T Suresh • Dr P S Bhattacharya • Dr C R Kundu • Dr V K Reddy • Dr Sajal Kakkar • Dr Deepak Gupta • Dr M Mrutyunjaya Rao • Dr Srinivasulu Reddy • Dr Mohana Priya PHYSICISTS • MR A C PRABU • MR A SRINU • MR PRASAD • DR ANIL KUMAR TECHNOLOGIST TEAM Acknowledgments 4/24/2021 89

×