STEREOTACTIC RADIOSURGERY VS CONVENTIONAL EBRT IN BRAIN
METASTASES
INTRODUCTION
INTRODUCTION
Certain tumours such as lung, breast
cancers can spread to the brain and form
brain metastases. Brain metastasis is a
neurologic disease and is said to be a
common problem in almost 40% of
patients whose cancers reach the
systemic level (Kleinberg, 2009). Brain
metastases are mainly multiple (two-
third of cases), but they also may be
isolated; their main sites are the
cerebral hemispheres (80%) and the
cerebellum (16%). They do not
commonly occur in the brainstem,
pituitary gland and the choroid plexus
(Kunkler, 2003). These brain
metastases can be treated with
palliative modality using several
techniques for instance the stereotactic
radiosurgery (SRS) and conventional
external beam radiation therapy (EBRT).
The two techniques can also be
combined in the treatment of brain
metastases. These two techniques are
the focus of this work, and are compared
in term of their impact to the treatment
of brain metastases in order to find out
the most advantageous for patients.
Every aspect of each of the two
techniques is looked at: dose
prescription, planning aspect, treatment
technique aspects, on treatment imaging
and verification, patient aspects and
advantages and disadvantages.
RESEARCH POSTER PRESENTATION DESIGN © 2011
www.PosterPresentations.com
CITY UNIVERSITY/ RADIOGRAPHY
Fig1. Stereotactic neurosurgery frame
(http://www.elekta.com/healthcare_int
ernational_stereotactic_neurosurgery.ph
p)
Fig2. Gadolinium-enhanced MRI scans of
brain metastases.
(http://www.google.co.uk/imgres?
imgurl=http://web.adu.edu.tr)
CONVENTIONAL EXTERNAL
BEAM RADIOTHERAPY
This palliative EBRT used to treat
multiple metastases includes the whole
brain and it as called the whole brain
radiation therapy (WBRT). WBRT is given
either as definitive treatment or as
adjuvant to surgery or to SRS.
PLANNING
The target volume includes the whole
brain if metastases are located in the
supratentorial region; but it if the
metastases are only located in the
cerebellum the treatment is given to the
infratentorial region.
Treatment
For the both regions patients are treated
supine, the head immobilised by a
thermoplastic head shell and the
treatment is given in two lateral parallel
opposed fields. MLC or lead blocks
fitted to the collimator are used to
shield the eyes (optic nerve).
The treatment is given using 6MV
photons or cobalt-60 in a dose of 30 Gy
given to the mid-point dose (MPD) in 10
daily fractions over 2 weeks, which
means 3 Gy per fraction.
Alain MAHUNGU
Before the treatment verification images
(anterior-posterior and lateral) are
taken and matched to the DRR’s.
The aims of WBRT include the treatment
of existing brain metastases and
preventing future metastases. However
its results are poor with the average
survival of between 3 and 5 months.
This is proved in a study conducted by
Lalondrelle and Khoo (2009) stating that
people with untreated brain metastases
have a median survival of about 4 weeks
from diagnosis but the addition of
corticosteroids can extend this survival
by another 4 more weeks; they add that
the WBRT further extends median
survival to 3-6 months
STEREOTACTIC RADIOSURGERY
SRS uses very small fields of less than 25
mm diameter and is one of the most
non-invasive options in the treatment of
brain metastases. The localization,
planning and treatment delivery in brain
metastases are made accurate because
these metastases are not infiltrative,
they have a relatively spherical shape,
not exceed 4 cm diameter, and are
located in the grey-white junction.
Planning
The patient is planned under local
anaesthetic and wears a reference frame
that is attached rigidly to the skull.
The determination of the gross tumour
volume (GTV) for SRS consists in the use
of contrast-enhanced (gadolinium)
volume on MRI images. The planning
target volume (PTV) is created by
extending the GTV by 1- 3mm in order to
include microscopic extension
ADVANTAGES AND
DISADVANTAGES
EBRT (WBRT)
ADVANTAGES
May prevent or delay progression of
symptoms
Treats multiple metastases
Can control large metastases
Less aggressive technique
Very available treatment
DISADVANTAGES
Not clear survival benefit (3-5 months)
in 50% of patients (Biswas et al, 2006)
Acute toxicity (headache, nausea,
vomiting), risk of infection
Treats a large amount of healthy brain
Longer course than SRS
High dose to healthy brain
SRS
ADVANTAGES
Rapid decrease of symptoms (headache,
seizure…)
Less toxicity and lower risk of
haemorrhage and infection (Biswas, et
al, 2006)
As effective as surgery+ WBRT
Effective in highly radioresistant
tumours
Median survival time: 7-15 months.
Less dose to surrounding healthy tissue
DISADVANTAGES
Can only control small tumours (2cm)
(Vogelbaum et al, 2006)
Aggressive technique
Absent technique in certain hospitals
 
CONCLUSION
This work has compared two treatment
techniques used in the treatment of
brain metastases that are EBRT (WBRT)
and SRS.
It has said that brain metastases are
very common in patients with a systemic
cancer. Regarding the prescriptions
WBRT seems to have a standard
prescription of 30Gy in 10 fractions,
while the prescription for the SRS
depends on the size of the tumour. Both
treatments can be given in a linear
accelerator, but there is a difference in
accessories used. Regarding the planning
the WBRT includes the whole brain, thus
its name, but for SRS there is a GTV that
needs to be covered by the prescribed
isodose. About patient aspects SRS is
more advantageous than WBRT and it
provides a rapid decrease of symptoms.
Regarding the survival rate SRS is again
better than WBRT with a median survival
time of 7- 15 months compared to 3- 5
months for WBRT.
REFERENCES
 
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Brain Metastases- Evidence based management. Journal of Cancer Research and
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Springer. Pp.345-361.
 
Kleinberg, L.R (2009) Brain Metastasis: A multidisciplinary approach. New York,
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Jayarao, M; Chin, L. S, and Regine, W. F (2009) Stereotactic radiosurgery for
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