A Cancer Care Ontario Organizational Guideline for the Delivery of Stereotactic Radiosurgery for Brain Metastasis in Ontario, Canada

Abstract

In Ontario, Canada, there is increasing demand for stereotactic radiosurgery (SRS) for brain metastases. Recommendations for safe SRS delivery are needed to ensure that patients receive an equitable level of care across the province. This guideline presents the minimal recommendations for the organization and delivery of SRS with respect to the multidisciplinary team, applicable technologies, imaging requirements, quality assurance program, and patient follow-up. Methods and Materials: The recommendations are based on the consensus opinion of the Cancer Care Ontario SRS for Brain Metastasis Guideline Development Group and clinical evidence when available. Primary consideration was given to the perceived benefits for patients and the small likelihood of harm arising from recommendation implementation. With the exception of the magnetic resonance imaging (MRI) follow-up strategy, all evidence was considered indirect and was provided by the working group in conjunction with their collective expertise in the field of SRS. Results: The application of SRS requires a multidisciplinary team consisting of a radiation oncologist, neurosurgeon, neuroradiologist, medical physicist, radiation therapist, and medical dosimitrist. Volumetric imaging scanning parameters must be set to ensure sufficient spatial resolution, geometric fidelity, and contrast signal for brain metastases to be adequately and reliably visualized, contoured, and planned. The MRI-to-treatment time interval should be as short as possible, ideally no more than 7 days and certainly no more than 14 days as a maximum. Quality assurance programs must ensure that the treatment unit is in compliance with the manufacturer and with national and international guidelines. Follow-up of patients undergoing SRS should consist of routine clinical visits with an MRI every 2 to 3 months for the first year; every 3 to 4 months for the second and third year; and thereafter as determined by the multidisciplinary case conference. Sources of support: The Program in Evidence-Based Care is a provincial initiative of Cancer Care Ontario supported by the Ontario Ministry of Health. All work produced by the Program in Evidence-Based Care and the Radiation Treatment Program is editorially independent from the Ontario Ministry of Health. Disclosures: Dr Sahgal has received honoraria for past educational seminars from Elekta AB, Accuray, Inc, and Varian Medical Systems and research grants from Elekta AB. Dr Sahgal also belongs to the Elekta MR Linac Research Consortium. Dr Greenspoon has been principal investigator on some studies related to radiosurgery and brain metastases at McMaster University (CEC.3, and involved in CE.7) and in-house smaller studies and has been involved in the Accuracy Fellowship at McMaster University, where the fellowship focus is stereotactic radiosurgery and stereotactic body radiation therapy. Dr Ruschin is the coinventor of and owns associated intellectual property specific to the image guidance system on the Gamma Knife Icon and is coinvestigator on Elekt...

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