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The treatment plans for stereotactic radiosurgery employ small, circular, noncoplanar fields applied in a series of arcs, or with synchronous rotation of the accelerator gantry and patient support assembly. Primary or metastatic brain tumors and arterial-venous malformations are localized in relation to a stereotactic head frame using CT, MRI, and angiography. As x-ray doses in the range of 20-40 Gy are delivered in a single treatment, it is critical that the dose distribution produced by the accelerator accurately reflect the one developed by the treatment planning computer. Until the advent of Fricke-infused gels, whose NMR characteristics are changed by irradiation, there was no practical method for assessing the accuracy of x-ray beam positioning on a target that was localized by both CT and MRI. A stereotactic head frame was attached to a hollow glass head filled with a Fricke-infused gel. A 2-mm target point at approximately the center of this manikin was localized by CT and MRI. The head frame was then mounted to the patient support assembly of a linear accelerator, and given a dose of 40 Gy to the isocenter from 6-MV x rays using a modified version of the dynamic stereotactic radiosurgery plan developed in Montreal. Subsequent MRI showed the target point at the center of the dose distribution, thus confirming the accuracy of the stereotactic radiosurgery procedure. This demonstrated the unique characteristics of the Fricke-infused gel for the simultaneous localization of x-ray beams in three dimensions.

OBJECTIVEFunctional Gamma Knife radiosurgery (GKRS) procedures have been increasingly used for treating patients with tremor, trigeminal neuralgia (TN), and refractory obsessive-compulsive disorder. Although its rates of toxicity are low, GKRS has been associated with some, if low, risks for serious sequelae, including hemiparesis and even death. Anecdotal reports have suggested that even with a standardized prescription dose, rates of functional GKRS toxicity increase after replacement of an old cobalt-60 source with a new source. Dose rate changes over the course of the useful lifespan of cobalt-60 are not routinely considered in the study of patients treated with functional GKRS, but these changes may be associated with significant variation in the biologically effective dose (BED) delivered to neural tissue.METHODSThe authors constructed a linear-quadratic model of BED in functional GKRS with a dose-protraction factor to correct for intrafraction DNA-damage repair and used standard single-fraction doses for trigeminal nerve ablation for TN (85 Gy), thalamotomy for tremor (130 Gy), and capsulotomy for obsessive-compulsive disorder (180 Gy). Dose rate and treatment time for functional GKRS involving 4-mm collimators were derived from calibrations in the authors' department and from the cobalt-60 decay rate. Biologically plausible values for the ratio for radiosensitivity to fraction size (α/β) and double-strand break (DSB) DNA repair halftimes (τ) were estimated from published experimental data. The biphasic characteristics of DSB repair in normal tissue were accounted for in deriving an effective τ1 halftime (fast repair) and τ2 halftime (slow repair). A sensitivity analysis was performed with a range of plausible parameter values.RESULTSAfter replacement of the cobalt-60 source, the functional GKRS dose rate rose from 1.48 to 2.99 Gy/min, treatment time fell, and estimated BED increased. Assuming the most biologically plausible parameters, source replacement resulted in an immediate relative BED increase of 11.7% for GKRS-based TN management with 85 Gy, 15.6% for thalamotomy with 130 Gy, and 18.6% for capsulotomy with 180 Gy. Over the course of the 63-month lifespan of the cobalt-60 source, BED decreased annually by 2.2% for TN management, 3.0% for thalamotomy, and 3.5% for capsulotomy.CONCLUSIONSUse of a new cobalt-60 source after replacement of an old source substantially increases the predicted BED for functional GKRS treatments for the same physical dose prescription. Source age, dose rate, and treatment time should be considered in the study of outcomes after high-dose functional GKRS treatments. Animal and clinical studies are needed to determine how this potential change in BED contributes to GKRS toxicity and whether technical adjustments should be made to reduce dose rates or prescription doses with newer cobalt-60 sources.

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