STEREOTAXY EXPERIENCE- SRS.SBRT

1. SRS/SBRT
MAHATMA GANDHI CANCER HOSPITAL AND
RESEARCH INSTITUTE, VISAKHAPATNAM
OUR EXPERINCE OF FIRST 50 CASES
DR KANHU CHARAN PATRO
1

2. WHAT IS SRS/SBRT?
• Stereotactic radiosurgery (SRS) uses many precisely
focused radiation beams to treat tumors and other
problems in the brain, neck, lungs, liver, spine and
other parts of the body.
• It is not surgery in the traditional sense because
there's no incision.
• SRS is for cranial
• SBRT for extracranial
2

3. THE DIFFERNCE CONVENTIONAL VS STEREOTAXY
E. H. Balagamwala/Technology in Cancer Research and Treatment/2012 3

4. The duo
• High dose
• Strict immobilization
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5. 5

6. • Massive vascular damage causes indirect tumor death-it is endothelial cell
inflammation and apoptosis via the sphingomyelin pathway causing
subsequent microvascular dysfunction that are the triggers for tumor cell
death
• 4 r of radiobiology in different manner
• No Repair after ablative dose
• Treatment is for short period no chance of Repopulation
• No Reoxygenation of hypoxic cells due to massive vascular destruction by
SRS/SBRT
• Redistribution dose not happen as more cells die because of massive cell
death
• Massive immunogenic reaction
• Abscopal effect
RADIOBIOLOGY BEHIND STEROTAXY
6

7. The spectrum
• SRS
– Smaller lesion usually less than 3 cm.
– Single fraction
• FRACTIONATED SRS
– Relatively larger tumor
– 1 to 5 fractions
• SRT
– Larger tumor usually more than 3 cm
– Close to vital structures
7

8. The spectrum
• Malignant
– Metastasis
– Recurrent Gliomas
• Benign
– Arteriovenous Malformation
– Vestibular Schwannoma
– Pituitary
– Cavernomas
• Functional
– Trigeminal Neuralgia
– Tremor
– Epileptic Focus
8

9. The wide spectrum
Cranial
– Metastasis
• De novo
• After WBRT
– Arteriovenous malformation
– Vestibular schwannoma
– Reirradiation glioma
– Glomus jugularae
– Hamartoma
– Cavernoma
– Meningioma
– Trigeminal neuralgia
– Tremor
– Epilepsy
Extracranial
– Bone metastasis
– Prostate
– Lung primary/ metastasis
– Pancreas
– Adrenal metastasis
– Liver metastasis/HCC
– Spine metastasis
– Nodal recurrence
– Head and neck reirradiation
9

10. • Malignant cases -- Weeks to months
• Benign cases -- Months to years
• Functional cases -- Days
• Different criteria for different tumors e.g
– RECIST
– PERCIST
– RANO
– And many more
RESPONSE EVALUATION
10

11. WHAT are the requirements?
• Micro MLC/cone
• Planning system
• Imaging
• Immobilization
• Respiratory Motion management system
• QA accessories
• CBCT
• Protocols
11

12. WHAT we have – machine
12

13. WHAT we have – micro MLC
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14. WHAT we have – CONE
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15. WHAT we have – immobilization
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FRAXION

16. WHAT we have – immobilization
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17. WHAT we have – motion management
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SYMMETRY

18. WHAT we have – motion management
18
Abdominal compression

19. We have – ABC
19
ABC- ACTIVE BREATH COORDINATOR

20. • CT
• PETCT
– DOTA
– PSMA
– FDG
• MRI
IMAGING WE HAVE
20

21. WHAT we have – planning system
21

22. WHAT we have? – Ray Search planning system
22
FIRST IN INDIA-PHOTON

23. WHAT we have – verification system
23

24. • CBCT CORRECTIONS
Set-up verification-CBCT
24

25. WHAT we have – Hexapod
25

26. • HEXAPOD CORRECTIONS
Set-up verification- HEXAPOD
26

27. • MECHANICAL ISOCENTER CHECK
– WINSTON LUTZ TEST
• POINT DOSE VERIFICATION
• TOLERANCE-1MM
Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015
QA part
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What we follow?

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Approval

33. Started on July 2019
33

34. Cases completed till today
34

35. Cases completed till today
35
 Brain metastasis 16
 Brain metastasis after whole brain RT 8
 Brain metastasis cavity SRS 3
 Vestibular schwannoma 5
 Arteriovenous malformation 1
 Meningioma 5
 Pituitary 1
 Spine metastasis 3
 Bone metastasis 1
 Cranial cavernoma 2
 Liver metastasis 3
 Hepatocellular carcinoma 1
 Lung cancer 1
 Nodal recurrence 1
TOTAL 51

36. OUR STEREOTAXY EXPERIENCE
36

37. BRAIN METASTASIS SRS
CASE-1
37

38. • NAME
• UMR
• PRESENTATION • 70 YEAR FEMALE
• TRIPLE NEGATIVE BREAST CANCER
• POST MRM
• POST RT/CHEMO
• 6 MONTH FOLLOW UP
• PRESENTED WITH HEADACHE AND GIDDINESS
• MRI • 2.2cm x2.2 cm LESION
• LT.OCCIPITAL LOBE
• RING ENHANCEMENT
• NO MASS EFFECT
• NO MID LINE SHIFT
• MINIMAL EDEMA
• PET CT • MULTIPLE LUNG NODULES
• BRAIN LESION INCREASED Uptake
• SRS • SRS
• 18Gy/1#
Case details
38

39. Pre SRS
39

40. SRS PALN
40

41. POST SRS 3 MONTHS
41

42. BRAIN METASTASIS CAVITY SRS
CASE-2
42

43. • NAME
• UMR
• PRESENTATION • SEIZURES, UNCONSCIOUS
• MRI • 3.2X3.2CM, LEFT OCCIPITAL LOBE,EDEMA,CONTRAST
ENHANCEMNET
• SURGERY • TOTAL EXCISON
• BIOPSY • METASTATIC PAPILLARY ADENOCARCINOMA
• PET CT • RT LUNG LESION
• MULTIPLE NODULE BOTH LUNG
• LESION IN BRAIN
• MEDIASTINAL NODE
• SRS • CAVITY SRS 30Gy/5#
• IHC • EGFR+VE
• EXON21 MUTATION
• ALK NEG
• TTF1 +VE
• CHEMO • PEMETRXED AND CARBOPLATIN
• OMERTINIB 80MG
Case details
43

44. Pre op
44

45. Post op 1 month
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46. 46
FRACTIONATED SRS
• ADJACENT DURA and
SURGICAL TRACT
• BONE FLAP INNER PART
• CAVITY PROPER
• DURAL SINUS
• ENHANCING COMPONENT

47. Post RT 3 months
47

48. VESTIBULAR SCHWANNOMA SRS
CASE-3
48

49. • NAME
• UMR
• PRESENTATION • 59 year male
• Diagnosed case of vestibular schwannoma
• Right side
• P/w Slight decreasing in hearing loss-4 - 5 months
• No facial numbness
• MRI • Intracanalicular and extra canalicular component
• Touching brainstem
• No cystic component
• Minimal enhancing
• Impending 5th nerve
• SRS • SRS
• 25Gy/5#
Case details
49

50. LT. Fifth
nerve
RT. Fifth
nerve
50

51. Beam arrangement
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52. 6MONTH FOLLW UP
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53. NODAL RECURRENCE SBRT
CASE- 4
53

54. • NAME
• UMR
• Diagnosis • Cancer cervix with common iliac node
• RADIATION • EBRT –VMAT SIB 50Gy/25# -56Gy/28#
• REGULAR FOLLOW UP • Post RT 3month - CR
• Presented with • DVT and left leg pain
• PET • Nodal recurrence same area
• Planned SBRT • 30Gy/5#
• PET POST SBRT 3M • Decreased SUV value
• Now • Follow/up
Case details
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At diagnosis

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At 3 month post RT

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At 1 year post RT

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Planned SBRT

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At 3 month post SBRT

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At 6 month post SBRT

61. LIVER METASTASIS SBRT
CASE-5
61

62. • NAME
• UMR
• PRESENTATION • 50 YEAR
• MALE
• COLON CANCER
• FOUND LIVER MET DURING SURGERY
• 2 LESIONS
• PET • 2 LESIONS
• SEGMENT VIII SUV-13
• SEGMENT V
• FNAC • ADENO
• CP SCORE • A
• SBRT • 40Gy/5# WITH DIBH
Case details
62

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65. SPINE METASTASIS SBRT
CASE-6
65

66. • NAME
• UMR
• Diagnosis • Ca Lung left lower lobe with D11 bone metastasis
• Presented with • Cough with expectoration, Pain over left chest wall,
Upper backache
• PET • Soft tissue enhancing lesion 5.2cm in LLL abutting pleura
s/o primary
• Hypermetabolic lesion in D11 vertebra (SUV max- 8) –
s/o metastasis
• Planned SBRT • 25Gy/5#
• PET POST SBRT 3M • Complete metabolic resolution of the D11 vertebral
lesion s/o favourable response to treatment
• COURTESY • DR VKR
Case details
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Spine metastasis

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Target delineation

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Planned SBRT

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3 month follow up scan

71. HEPATOCELLULAR CARCINOMA SBRT
CASE-7
71

72. • NAME
• UMR
• Diagnosis • Hepatocellular carcinoma
• Presented with • Diagnosed during screening
• PET • Small lesion in segment 7
• Planned SBRT • 45Gy/3#
• PET POST SBRT 3M • Complete resolution
• Now • f/up
• COURTESY • DR VKR
Case details
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73. CT/MRI
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74. TARGET
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75. SBRT PLAN
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76. 3 month follow up
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77. BONE METASTASIS SBRT
CASE-8
77

78. • NAME
• UMR
• Diagnosis • Metastatic Carcinoma Breast
• Presented with • Pain over left hip
• PET • Increased tracer uptake is seen in left acetabulum along
the posterior margin and the left ischium showing
sclerotic changes (SUV max - 6)
• Planned SBRT • 33Gy/3#
• PET POST SBRT 3M • No definite focal hypermetabolic or abnormally
enhancing lesion
• Increased sclerotic changes in the lesions noted in left
acetabulum, ischium and inferior pubic ramus – s/o
complete metabolic response
• COURTESY • DR PSB
Case details
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Isolated bone mets

80. TARGET
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Planned SBRT

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At 6 month follow up

83. AVM SRS
CASE-9
83

84. • NAME
• UMR
• PRESENTATION • 23 year female
• ECOG-1
• Sudden onset headache
• Weakness of left upper and lower limb
• Evaluated outside
• Images not available
• MRI • Location-Right high posterior parietal vascular malformation
• Malformation size 3.4cm x 2.9cm x3.4cm
• Nidus size 1.6cm x 1.4cm
• Arterial supply- Pericollasal and collasomarginal branches of right
anterior cerebral artery
• Venous drainage- cortical veins along the right posterior parietal
region
• Hemoglobin degradation products with gliosis and
enchephalomalacia.
• SBRT • 18Gy/1#
84

85. MR ANGIO after 3 months
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86. T1/T2- after 3 months
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87. DSA THE GOLD STANDARD
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88. CT ANGIO
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89. The beam arrangement
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90. 6 month follow up
90

91. MENINGIOMA SRS
CASE-10
91

92. • NAME
• UMR
• PRESENTATION • HEADACHE LEFT SIDED, LEFT EYE PAIN
• MRI • 2.2×1.9×2.3CM, INTENSELY ENHANCING EXTRA AXIAL LESION T2W
HYPOINTENSE & ISOINTENSE T1W ON LEFT SIDE POSTERIOR TO
CAVERNOUS SINUS AND INDENTING PONS. LATERALLY ENCASING
LEFT TRIGE
• SURGERY • NEAR TOTAL EXCISON
• HPE • S/O TRANSITIONAL MENINGIOMA (WHO GRADE I)
• DOTA PET CT • 1.2×0.6 CM LESION NOTED IN THE LEFT PETROCLIVAL REGION
,POSTERIOR TO THE CAVERNOUS SINUS WITH SUV MAX - 7
• PLAN • SRS – 15Gy IN 1#
Case details
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Petroclival meningioma

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Dota scan

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SRS plan

96. 6 month follow up
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97. Pituitary
CASE-11
97

98. • NAME
• UMR
• PRESENTATION • Vomiting, Head reeling sensation, Involuntary movements of all
limbs
• MRI 1. 2.3 × 1.6 × 1.6 cm, Dumbbell shaped lesion in sellar region
2. Extending into Suprasellar location
3. Pituitary gland not separated from lesion
4. Optic chiasm – compressed & superiorly displaced
5. Doubtful B/L Parasellar extension (R>L) with encasement of
cavernous segment B/L ICA (R>L)
• SURGERY • Endoscopic Trans sphenoid Excision and Near total excision
• BIOPSY • F/S/O Pituitary Macro adenoma
• SRS • FSRT – 25Gy / 5#
• IHC • Synaptophysin +VE ,
• Chromogranin +VE
Case details
98

99. Target
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100. SRS PLAN
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101. 6 month follw up- awaited
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102. GLOMUS JUGULARAE
CASE-12
102

103. • NAME
• UMR
• PRESENTATION • Headache, difficulty in swallowing, Hoarseness of voice, Tinnitus
, reduced hearing, Nasal regurgitation × 6 months
• MRI • 2.5 x2 cm, Brilliantly enhancing, extracranial lesion in Left jugular
foramen
• Hypo on T1 and Iso on T2
• Erosion of carotid canal and jugular foramen
• SURGERY • Excision of Glomus jugulare done by FISCH type approach
• BIOPSY • well defined nests separated by highly vascularized fibrous
septae[zelle ballen pattern]
• SRS • 14Gy/1#
• IHC • Synaptophysin positive
• S100 positive
• COURTESY • DR PSB
Case details
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104. GTV WITH PTV 1MM
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105. SRS PLAN
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106. 6 month follow up- awaited
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107. REMEMBERING THE LEGENDS
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114. if you are thinking about me as legend
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115. ACKNOWLEDGMENTS-CONSULTANTS
115
DR C R KUNDU DR P S BHATTACHARYYA
DR V K REDDY DR M MRUTYUNJAYA

116. ACKNOWLEDGMENTS- PHYSICISTS
116
A C PRABU A ANIL KUMAR A SRINU P PRASAD

117. ACKNOWLEDGMENTS- TECHNOLOGISTS
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118. THE GUIDANCE
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