NON SURGICAL TREATMENT OF

BRAIN TUMORS

MODERATOR PRESENTOR-
DR. MANISH AGRAWAL DR. AKSHIT AGRAWAL
DR. JITENDRA SINGH
SHEKHAWAT
DR MANMOHAN SINGH
DR. SURENDRA SAINI
 Treatment options:-
1) Radiotherapy.
2) Chemotherapy
3) Immunotherapy
4) Targeted therapy.
TYPES OF RADIOTHERAPY TECHNIQUES
• CONVENTIONAL 2 D APPROACH
• 3 D CONFORMAL RADIOTHERAPY (3DCRT)
• STEREOTACTIC RADIOSURGERY AND
STREOTACTIC RADIOTHERAPY.
• BRACHYTHERAPY
• PROTON BEAM THERAPY.
 TWO DIMENSIONAL PLANNING OF BRAIN
TUMOR
Portals
• TWO PARALLEL AND OPPOSITE WEDGE LATERAL FIELDS AND
ONE ANTERIOR OR VERTEX BEAM THAT ENTERS ABOVE THE
EYES.
• THE CENTRE OF PITUTARY IS LOCATED AT POINT 2-2.5
ANTERIORLY TO TARGET AND 2-2.5 CM SUPERIORLY TO THAT
POINT.
• TAKING THIS POINT AS CENTRE A FIELD OF 4X4 CM- 6X6 CM IS
MARKED.
ENERGY
6-10 Mev OR Co 60.
• DOSE-
• NONFUNCTIONING TUMORS 45-50.4 Gy @ 1.8
Gy/#.
• FUNCTIONAL TUMORS 50.4-54 Gy @ 1.8 Gy/#.
PLANNING CT:
• DIFFERENT FROM DIAGNOSTIC IMAGING.
• USE APPROPRIATE IMMOBILIZATION DEVICES.
• IMAGING DONE IN TREATMENT POSITION.
PLANNING MRI:
• DONE IN TREATMENT POSITION

IMAGES ARE THEN TRANSFERRED TO PLANNING

SYSTEM
 2D planning for brain tumor
• Countour target outline.
• Place a field.
• Immobilization.
PLACE A FIELD AND CONTOUR TARGET
OUTLINE
 IMMOBILIZATION
•Head rest.
•Thermoplastic mask.
•Base plate.
2D Beam Arrangements
 Conventional planning
Disadvantages:-
• Irradiation of large volume of brain with
normal brain tissue.
• Higher toxicity and side effect.
• Lack of 3D visualization of Tumor.
(2 D planning of 3D tumor)
 3D CRT
• BETTER THAN CONVENTIONAL 2D.
• LESS TOXICITY AS MORE DIRECTED THERAPY.
PLANNING CT:
• DIFFERENT FROM DIAGNOSTIC IMAGING.
• USE APPROPRIATE IMMOBILIZATION DEVICES.
• IMAGING DONE IN TREATMENT POSITION.
PLANNING MRI:
• DONE IN TREATMENT POSITION

IMAGES ARE THEN TRANSFERRED TO PLANNING

SYSTEM
 IMAGING
•CT
•CT- MR FUSION
•PET SCAN – LIMITED USE
ONLY (EMERGING)
TARGET DELIENATION
BEAM SHAPING
MULTILEAF COLLIMATORS (MLC)
PLAN EVALUATION
 3 D PLANNING
ADVANTAGES:-
• IDEAL FOR ALL
CASES.
•CONFORMAL
•MAXIMUM SPARING
OF NORMAL TISSUE.
•LOWER TOXICITY.
 Stereotactic radiosurgery (SRS)
• Stereotactic radiosurgery (SRS) is a non surgical radiation
therapy used to treat functional abnormalities and small
tumors of brain.
• It can deliver precisely targeted radiation in fewer high dose
treatments then traditional therapy, which can help preserve
healthy tissue.
• It uses stereotaction (guiding) devices capable of pinpointing
targets within the brain and helps in exact localization of the
lession.
 Stereotactic Radiosurgery Stereotactic Radiotherapy
Dose per fraction High Low
Number Of Fraction 1 Multiple
Targeting Accuracy < 1 mm 3- 20 mm

•SRS and SRT are very similar, but SRS delivers a large dose
of radiation on a single day and SRT has a fractionated
treatment schedule.
•Although the total dose in SRT may be larger than SRS, but
any single day will have a much smaller dose delivery.
 INDICATIONS
SRS:-
• Benign And Malignant Tumors.
• Well Circumscribed Targets < 4 Cm Diameter.
• Arterio-venous Malformations.

SRT:-
• Lesions > 4 Cm
• Lesions Located Near Critical Structures.
 ADVANTAGES
• Decreased Length Of Hospital Stay.
• Decreased Hospital Stay.
• Lower Immediate Post Treatment Morbidity And Mortality.
 MACHINES
• GAMMA KNIFE.
• PROTON THERAPY.
• X KNIFE-
- CYBER KNIFE
- ELEXETA
- VARIAN.
• Advantages:-
• Very high target precision.
• Multiple targets can be treated during a single
treatment session.

• Disadvantages:-
• Painful stereotactic head frame.
• Difficult to treat lessions located at the
periphery of the brain.
• Co source decay – increase treatment cost and
time.
 X KNIFE
• Treatment By High Enerygy X Rays.
• Mostly Non Invasive
• Equally Effective
• Cheaper.
 BRACHYTHERAPY
• BIS-CHLORONITROSOUREA (BCNU)-
IMPREGNATED BIODEGRADABLE POLYMER
(GLIADEL WAFER) MAY BE CONSIDERED FOR
INTRAOPERATIVE PLACEMENT OF FROZEN
SECTION REVEALS HIGH GRADE GLIOMA.
• I-125 LIQUID SOAKED WAFERS ARE ALSO
USED.
 Whole brain Radiotherapy
• Whole brain Radiotherapy is treatment of choice
for many patients because of high incidence of
multiple Mets.
• Goal of WBRT is to limit tumor progression and in
middle term , to limit the use of corticosteroids.
• The optimal dose of iorradiation is unknown but
usually in clinical practice – 20 Gy in 5 fractions
over 1 week, 30 Gy in 10 to 40 Gy in 20 fractions
over 4 weeks is used.
• Complications :-
• Alopecia
• Transient worsening of neurological symptoms
• Otitis
• Long term- memory loss, dementia and
decreased concentration.
• Xerostomia.
 Hippocampal sparing
Supine position
Mask
Ct- mri fusion
MENINGIOMA
 UNRESECTABLE OR RECURRENT
MENINGIOMA
• In patients in whom aggressive surgery is not an option, radiotherapy
may relieve symptoms and decrease the rate of tumor progression.
• Radiotherapy may be useful in the treatment of recurrent
meningioma.
• In a review by Miralbell et al.progression-free survival at 8 years for
patients treated with subtotal resection and radiotherapy at first
recurrence was 78% compared to 11% in patients treated with
resection alone (P = .001).
• Various chemotherapy treatments that have been used in patients
with recurrent meningiomas include combined doxorubicin and
dacarbazine or ifosfamide and mesna.
• Long-term low-dose daily hydroxyurea may have some activity.
 RADIOTHERAPY
• The goal of radiation therapy is to destroy any
remaining meningioma cells and reduce the
chance that the meningioma may recur.

• INDICATION
• Residual tumor left after surgery
• Recurrence
• Tumor couldn't be berated Surgically.
• Malignant histology
• Stereotactic radiosurgery (SRS) :aims several beams of powerful
radiation at a precise point. (Contrary to its name, radiosurgery
doesn't involve scalpels or incisions.
• Radiosurgery typically is done in an outpatient setting in a few hours.
• Radiosurgery established as an alternative therapy to surgery in well-
defined cases with small tumors in elderly or critically sick patients.
• Local control of small-sized intracranial meningiomas of a diameter
of 3 cm or less after SRS was comparable to Simpson Grade I
resection.
• Two to five fractions with doses of 4-10 Gy per fraction are
commonly used, resulting in total doses of 18-25 Gy.
• Fractionated stereotactic radiotherapy
(SRT) :delivers radiation in small fractions
over time, such as one treatment a day for 30
days.
• Tumors too large for radiosurgery could be
treated by this or those in an area that can't
tolerate the high intensity of radiosurgery —
such as near the optic nerve.
• Intensity-modulated radiation therapy
(IMRT) : This may be used for meningiomas
located near sensitive brain structures or those
with a complex shape.
• Proton beam radiation :uses radioactive
protons precisely targeted at the tumor,
reducing damage to the surrounding tissue.
• Drug :Drug therapy (chemotherapy) is rarely
used to treat meningiomas, but it may be used
in cases that don't respond to surgery and
radiation.
CHEMOTHERAPY
• CHEMOTHERAPY – DRUGS AND REGIMEN
• TARGETED THERAPY