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.

STEREOTAXY EXPERIENCE- SRS.SBRT

STEREOTAXY EXPERIENCE- SRS.SBRT

  • Sé el primero en comentar

STEREOTAXY EXPERIENCE- SRS.SBRT

  1. 1. SRS/SBRT MAHATMA GANDHI CANCER HOSPITAL AND RESEARCH INSTITUTE, VISAKHAPATNAM OUR EXPERINCE OF FIRST 50 CASES DR KANHU CHARAN PATRO 1
  2. 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. 3. THE DIFFERNCE CONVENTIONAL VS STEREOTAXY E. H. Balagamwala/Technology in Cancer Research and Treatment/2012 3
  4. 4. The duo • High dose • Strict immobilization 4
  5. 5. 5
  6. 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. 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. 8. The spectrum • Malignant – Metastasis – Recurrent Gliomas • Benign – Arteriovenous Malformation – Vestibular Schwannoma – Pituitary – Cavernomas • Functional – Trigeminal Neuralgia – Tremor – Epileptic Focus 8
  9. 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. 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. 11. WHAT are the requirements? • Micro MLC/cone • Planning system • Imaging • Immobilization • Respiratory Motion management system • QA accessories • CBCT • Protocols 11
  12. 12. WHAT we have – machine 12
  13. 13. WHAT we have – micro MLC 13
  14. 14. WHAT we have – CONE 14
  15. 15. WHAT we have – immobilization 15 FRAXION
  16. 16. WHAT we have – immobilization 16
  17. 17. WHAT we have – motion management 17 SYMMETRY
  18. 18. WHAT we have – motion management 18 Abdominal compression
  19. 19. We have – ABC 19 ABC- ACTIVE BREATH COORDINATOR
  20. 20. • CT • PETCT – DOTA – PSMA – FDG • MRI IMAGING WE HAVE 20
  21. 21. WHAT we have – planning system 21
  22. 22. WHAT we have? – Ray Search planning system 22 FIRST IN INDIA-PHOTON
  23. 23. WHAT we have – verification system 23
  24. 24. • CBCT CORRECTIONS Set-up verification-CBCT 24
  25. 25. WHAT we have – Hexapod 25
  26. 26. • HEXAPOD CORRECTIONS Set-up verification- HEXAPOD 26
  27. 27. • MECHANICAL ISOCENTER CHECK – WINSTON LUTZ TEST • POINT DOSE VERIFICATION • TOLERANCE-1MM Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015 QA part 27
  28. 28. 28 What we follow?
  29. 29. 29
  30. 30. 30
  31. 31. 31
  32. 32. 32 Approval
  33. 33. Started on July 2019 33
  34. 34. Cases completed till today 34
  35. 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. 36. OUR STEREOTAXY EXPERIENCE 36
  37. 37. BRAIN METASTASIS SRS CASE-1 37
  38. 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. 39. Pre SRS 39
  40. 40. SRS PALN 40
  41. 41. POST SRS 3 MONTHS 41
  42. 42. BRAIN METASTASIS CAVITY SRS CASE-2 42
  43. 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. 44. Pre op 44
  45. 45. Post op 1 month 45
  46. 46. 46 FRACTIONATED SRS • ADJACENT DURA and SURGICAL TRACT • BONE FLAP INNER PART • CAVITY PROPER • DURAL SINUS • ENHANCING COMPONENT
  47. 47. Post RT 3 months 47
  48. 48. VESTIBULAR SCHWANNOMA SRS CASE-3 48
  49. 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. 50. LT. Fifth nerve RT. Fifth nerve 50
  51. 51. Beam arrangement 51
  52. 52. 6MONTH FOLLW UP 52
  53. 53. NODAL RECURRENCE SBRT CASE- 4 53
  54. 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 54
  55. 55. 55 At diagnosis
  56. 56. 56 At 3 month post RT
  57. 57. 57 At 1 year post RT
  58. 58. 58 Planned SBRT
  59. 59. 59 At 3 month post SBRT
  60. 60. 60 At 6 month post SBRT
  61. 61. LIVER METASTASIS SBRT CASE-5 61
  62. 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
  63. 63. 63
  64. 64. 64
  65. 65. SPINE METASTASIS SBRT CASE-6 65
  66. 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 66
  67. 67. 67 Spine metastasis
  68. 68. 68 Target delineation
  69. 69. 69 Planned SBRT
  70. 70. 70 3 month follow up scan
  71. 71. HEPATOCELLULAR CARCINOMA SBRT CASE-7 71
  72. 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 72
  73. 73. CT/MRI 73
  74. 74. TARGET 74
  75. 75. SBRT PLAN 75
  76. 76. 3 month follow up 76
  77. 77. BONE METASTASIS SBRT CASE-8 77
  78. 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 78
  79. 79. 79 Isolated bone mets
  80. 80. TARGET 80
  81. 81. 81 Planned SBRT
  82. 82. 82 At 6 month follow up
  83. 83. AVM SRS CASE-9 83
  84. 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. 85. MR ANGIO after 3 months 85
  86. 86. T1/T2- after 3 months 86
  87. 87. DSA THE GOLD STANDARD 87
  88. 88. CT ANGIO 88
  89. 89. The beam arrangement 89
  90. 90. 6 month follow up 90
  91. 91. MENINGIOMA SRS CASE-10 91
  92. 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 92
  93. 93. 93 Petroclival meningioma
  94. 94. 94 Dota scan
  95. 95. 95 SRS plan
  96. 96. 6 month follow up 96
  97. 97. Pituitary CASE-11 97
  98. 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. 99. Target 99
  100. 100. SRS PLAN 100
  101. 101. 6 month follw up- awaited 101
  102. 102. GLOMUS JUGULARAE CASE-12 102
  103. 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 103
  104. 104. GTV WITH PTV 1MM 104
  105. 105. SRS PLAN 105
  106. 106. 6 month follow up- awaited 106
  107. 107. REMEMBERING THE LEGENDS 107
  108. 108. 108
  109. 109. 109
  110. 110. 110
  111. 111. 111
  112. 112. 112
  113. 113. 113
  114. 114. if you are thinking about me as legend 114
  115. 115. ACKNOWLEDGMENTS-CONSULTANTS 115 DR C R KUNDU DR P S BHATTACHARYYA DR V K REDDY DR M MRUTYUNJAYA
  116. 116. ACKNOWLEDGMENTS- PHYSICISTS 116 A C PRABU A ANIL KUMAR A SRINU P PRASAD
  117. 117. ACKNOWLEDGMENTS- TECHNOLOGISTS 117
  118. 118. THE GUIDANCE 118
  119. 119. 119

×