Stereotactic Radiation Therapy

(SRT) for brain tumors

Treatment Delivery & Setup Correction Strategies

 Brain SRT: Bullet points

• How much accurate should SRT be?

• How to manage interfraction uncertainties?

• How to manage intrafraction uncertainties?

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 Brain SRT: how much accurate should it be?

AIM: To identify an optimal margin about the gross target

volume (GTV) for stereotactic radiosurgery (SRS) of brain
metastases, minimizing toxicity and local recurrence
Patients with 1 to 3 brain metastases
<4 cm in greatest dimension
Thermoplastic face-mask
Linac based SRS (24, 18, and 15 Gy peripheral dose)
On-line IGRT CBCT
IJROBP 2014

• 1 mm GTV-PTV margin (40 lesions)

80 lesions included • 3-mm GTV-PTV margin (40 lesions)

Primary endpoint: local recurrence

Secondary endpoints: neurocognition Mini-Mental State Examination, Trail Making Test Parts A and B, quality of life,
radionecrosis, need for salvage radiation therapy, distant failure in the brain, and overall survival (OS)
Brain SRT: how much accurate should it be?

Local control after SRS

1y-LC 93% for the overall group
• 1-mm margin: 91% (p=0.51)
• 3-mm margin: 95%

Biopsy-proven radionecrosis alone in 6 lesions

• 1 mm margin: 1/40 pts (2.8%)
• 3-mm margin: 5/40 pts (15.2%) (p=0.1)

CONCLUSIONS:
SRS was well tolerated, with low rates of LR and RN in both
cohorts. However, given the higher potential risk of RN with a
3-mm margin, a 1-mm GTV expansion is more appropriate.

Kirkpatrick JP et al. IJROBP 2015

 Brain SRT: Bullet points

• How much accurate should SBRT be?

• How to manage interfraction uncertainties?

• How to manage intrafraction uncertainties?

[Enter DCID # here on master slide.]

Brain SRT: How to manage the interfraction uncertainties?
Which structure for image match?

a) Brain

b) Skull

c) Lesion
Brain SRT: How to manage the interfraction uncertainties?
Which structure for image match?
AIM: To evaluate whether the
position of brain metastases remains
stable between planning and
treatment in cranial stereotactic
IJROBP 2007 radiotherapy (SRT).

18 pts, 20 brain metastases

Single-fraction (17 lesions) or hypofractionated (3 lesions) image-guided SRT.
Median time interval between planning and treatment was 8 days
Before treatment
• cone-beam CT (CBCT)
• conventional CT after application of i.v. contrast
→Setup errors using automatic bone registration (CBCT) and manual soft-tissue registration
of the brain metastases (conventional CT) were compared
Brain SRT: How to manage the interfraction uncertainties?
Which structure for image match?

Treatment of intracranial pressure with steroids did not influence the position of the lesion relatively
to the bony anatomy
Guckenberger M, et al. IJROBP 2007
Brain SRT: How to manage the interfraction uncertainties?
Which image guidance?

a. Paired planar images

b. CBCT and 4DOF correction

c. CBCT and 6DOF correction

Brain SRT: How to manage the interfraction uncertainties?
Which image guidance strategy?
AIM: To investigate localization
accuracy for frameless intracranial
stereotactic-radiosurgery using 2D
orthogonal planar imaging and 3D
cone-beam CT (CBCT) in 6-degree-
of-freedom (6-DOF).

100 patients
Patients were initially positioned with a thermoplastic mask system and then aligned with
• orthogonal planar imaging
• 3D CBCT in 4-DOF
• 3D CBCT in 6-DOF.

The setup discrepancies were quantitatively analyzed

Brain SRT: How to manage the interfraction uncertainties?
Which image guidance strategy?

Translation Rotation Translation Rotation

Chang Z, et al. J Nucl Med Radiat Ther 2010

Brain SRT: How to manage the interfraction uncertainties?
Which image guidance strategy?

Rotational discrepancies may

compromise the adequate dose
coverage for the target while
delivering overdose to critical
organ
• if the tumor has an irregular
shape and it’s close to critical
organs

Chang Z, et al. J Nucl Med Radiat Ther 2010

Brain SRT: How to manage the interfraction uncertainties?
Which image guidance strategy?

The first purpose was to characterize the sensitivity

of single-met per iso and multimet per iso
treatment plans to uncorrected patient motion

Med Phys. 2016

72 brain metastases (29 patients)

25 mets were treated individually (“single-met per iso plans”)
47 mets were treated in a plan simultaneously with at least one other met (“multimet per iso plans”)

For each met, the proportion of the gross tumor volume that remained within the 100% prescription
isodose line was estimated under the influence of combinations of translations and rotations (0.0–3.0
mm and 0.0◦–3.0◦, respectively).
Brain SRT: How to manage the interfraction uncertainties?
Which image guidance strategy?

Change in GTV coverage according to posistional shifts

Outliers: mets that were

Multi-met per iso at considerable distance
from isocenter

Yock AD, et al. Med Phys. 2016

 Brain SRT: Bullet points

• How much accurate should SBRT be?

• How to manage interfraction uncertainties?

• How to manage intrafraction uncertainties?

[Enter DCID # here on master slide.]

Brain SRT: How to manage the intrafraction uncertainties?

Immobilization with trUpoint ARCH

(CIVCO) is accomplished using multiple
components - a custom head support,
bite tray, thermoplastic mask and
nasion cushion

Maximum intrafractional motion was 2.0 mm in the longitudinal direction; 95%

of the total shifts were <1.4 mm. The linear regression showed a weak but
significant influence (R(2) = 0.26, P = .01) of the treatment time on the total
intrafractional shift.
Lang S, et al. Pract Radiat Oncol. 2015
Brain SRT: How to manage the intrafraction uncertainties?
VisionRT is a system which tracks a patient’s position before and during radiation therapy, to aid
in setup and treatment accuracy

• tracks the skin surface (using proprietary 3D stereo camera units)

• compares it to the ideal position with submillimetric accuracy
• automatically gives signal for the treatment delivery system to pause radiation if the patient moves
out of the desired position

No need for tattoos or additional radiation

 Brain SRT: How to manage the intrafraction uncertainties?

AlignRT

AIM: To establish a new clinical procedure in

frameless SRS for patient setup verification at
treatment couch angles as well as for
head‐motion monitoring during treatment using
video‐based optical surface imaging (OSI)

Med Phys 2011

Main results
• The accuracy of the OSI in 1D motion detection was found to be 0.1 mm with uncertainty of ±0.1 mm using the head
phantom.
• The OSI registration against simulation computed tomography (CT) external contour was found to be dependent on the
CT skin definition with ∼0.4 mm variation
• For frame‐based SRS patients, head‐motion magnitude was detected to be <1.0 mm and <1.0° for 98% of treatment time
• For frameless SRT/SRS patients, similar motion magnitudes were observed (<1.1 mm and 1.0° for 98% of treatment time)
→Head‐motion monitoring using near‐real‐time surface imaging provides adequate accuracy and is necessary for
frameless SRS in case of unexpected head motion that exceeds a set tolerance
 Brain SRT: How to manage the intrafraction uncertainties?

AlignRT
AIM: To evaluate the initial clinical experience
with a frameless and maskless technique for
stereotactic radiosurgery using minimal patient
immobilization and real-time patient motion
monitoring during treatment

PRO 2012
AlignRT was used for
• Initial setup using the surface of the patient obtained from the planning CT scan.
• Initial setup was confirmed and finalized with cone-beam CT (CBCT) prior to treatment
• Patients were monitored during treatment with surface imaging, and a beam hold-off was initiated when the patient's
motion exceeded a prespecified tolerance (1-2 mm).
Main results
• Average total setup time: 26 minutes (14 minutes for surface imaging)
• Average treatment time: 40 minutes.
• 35% patients needed repositioning during the treatment.
• The average shifts identified from CBCT after initial setup with surface imaging were 1.85 mm in the anterior-posterior
direction, and less than 1.0 mm in the lateral and superior-inferior directions.
• The longest treatment times happened for patients who fell asleep on the treatment table and were moving involuntarily.
 Brain SRT: How to manage the intrafraction uncertainties?

AlignRT

AIM: to report the UCSD SRS experience and

update the clinical outcomes using AlignRT in the
treatment of brain metastases (previous
experience published in 2012, 44 patients)

Retrospective study
Transl Cancer Res 2014

163 patients totaling 490 lesions and 45 post-operative cavities

Surface Image Guided RS: median delivery of 1 fraction (range, 1-5 fraction) and to a median dose of 22 Gy (range, 12-30 Gy).
Main results
Median follow-up: 6.7 months (range, 0.5-45.1 months
• Actuarial 6- and 12-month local control: 90% and 79%
• Actuarial 6- and 12-month overall survival: 80% and 56%

→Outcomes comparable to those with conventional frame-based and frameless SRS techniques
→Greater patient comfort with an open-faced mask and fast treatment time
 Brain SRT: take home messages
Treatment Delivery & Setup Correction Strategies
• Image guidance for brain SRT should aim at a repositioning accuracy of less than 1
mm

• The 3D–3D co-registration of the plan CT and daily CT scans with image match on
the skull is an adequate surrogate of the target position

• 6DOF set up correction is critical (particularly for targets with irregular shape that
are close to OARs, and for multiple targets that are treated with a single isocenter)

• Head‐motion monitoring using near‐real‐time surface imaging provides adequate

accuracy and it’s necessary for frameless SRS in case of head motion that may
exceed a set tolerance
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