Breathing-motion-compensated robotic guided stereotactic body radiation therapy

Stera, Susanne; Balermpas, Panagiotis; Chan, Mark K.H.; Huttenlocher, Stefan; Wurster, Stefan; Keller, Christian; Imhoff, Detlef; Rades, Dirk; Dunst, Jürgen; Rödel, Claus; Hildebrandt, Guido; Blanck, Oliver

doi:10.1007/s00066-017-1204-z

Cited by 26 publications

(29 citation statements)

References 47 publications

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“…Treatment planning was performed using MultiPlan (Accuray Inc.) for the CyberKnife and Leksell Gamma Plan 8.3.1 (Elekta) for the Gamma Knife System according to international best practice guidelines [11]. For the CyberKnife, a mean GTV dose optimization [12] was performed whenever necessary to generate Gamma Knife like plans with high central tumor doses. SRS was applied in a single fraction per metastasis.…”

Section: Treatment and Follow-upmentioning

confidence: 99%

Stereotactic radiosurgery combined with immune checkpoint inhibitors or kinase inhibitors for patients with multiple brain metastases of malignant melanoma

et al. 2019

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The aim was to evaluate toxicity and oncological outcome of combined stereotactic radiosurgery (SRS) and immunotherapy or targeted therapy in patients with multiple brain metastases originating from malignant melanoma. Despite the fact that both SRS and kinase inhibitors or immune checkpoint inhibitors are considered standard treatment options for this indication, the optimal combination and sequence of these modalities remains largely unknown, especially for patients with a high number of brain metastases. For this retrospective analysis, conducted in two large SRS dedicated centers, we identified patients with brain metastases from malignant melanoma and simultaneous application of immunotherapy or targeted therapy within 30 days of SRS. Forty-eight patients with a total of 250 lesions (median: 3) were treated in 65 single fraction SRS sessions from 2012 to 2018. After a median follow-up of 8.3 months (range: 1.2-43.6 months), the 6-month and 1-year overall survival rates were 75.3 and 50.8%, respectively. The local control rate at one year was 89.5%. Immunotherapy and the application of systemic treatment directly before or concomitant to SRS were both associated with improved overall survival (P = 0.037 and 0.045, respectively). We observed four grade III toxicities, of which only two can be clearly attributed to the combined treatment. Various combinations of SRS and kinase inhibitors or immune checkpoint inhibitors appear feasible and provide promising oncological results and safety profiles for treating few (n = 1-4) and also multiple (n ≥ 5) melanoma brain metastases.

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Section: Treatment and Follow-upmentioning

confidence: 99%

Stereotactic radiosurgery combined with immune checkpoint inhibitors or kinase inhibitors for patients with multiple brain metastases of malignant melanoma

et al. 2019

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“…Indikationen sind z. B. Knochen-oder Lymphknotenmetastasen [7], Lungentumoren (primär und sekundär) [8], Prostatakarzinome [9] und Tumoren der Niere, Nebenniere oder des Pankreas [10]. Für primäre Lebertumoren [11 -13], u. a. auch in Kombination mit anderen Verfahren (z.…”

Section: Stereotaktische Strahlentherapie Im Körperstammbereichunclassified

“…Bei diesem Verfahren werden je nach Größe, Anzahl und Lage der Lebermetastasen multiple 1-3 mm große Goldpartikel in die Nähe der Tumoren eingebracht und dienen als Surrogat für die Tumorposition und -bewegung. Diese Fiducial-Marker werden zumeist minimalinvasiv mittels CToder Ultraschallbildführung perkutan über 17-22 G (Gauge) dicke Nadeln implantiert [8,19,33]. [28,30].…”

Section: Stereotaktische Strahlentherapie Im Körperstammbereichunclassified

“…mittlere GTV-Dosis erscheint dabei einer der wichtigsten Faktoren für die lokale Kontrolle zu sein, jedoch ohne erkennbares Dosis-Wirkungs-Plateau für Lebermetastasen [8,18,19,23,26]. Die verschriebene PTV-Randdosis hingegen erreicht ein gewisses Plateau bei höheren Dosen über 3 × 14 Gy [8,19,22], und die notwendige Plateaudosis erscheint gerade bei homogeneren Dosisverteilungen und/oder Bestrahlungstechniken ohne aktive Bewegungskompensation deutlich höher als mit inhomogenen Bestrahlungstechniken mit aktiver Bewegungskompensation [8, 20 -23, 26]. Dies spricht wiederum für die Verwendung einer hohen zentralen bzw.…”

Section: Lokale Kontrolleunclassified

“…die Randdosis reduziert werden muss [22,23]. Diese Limitierung kann jedoch unter Verwendung von hohen zentralen Dosisopti- mierungen im Tumorkern fast vollständig überwunden werden [8,19]. Am Ende zeigt sich auch, dass die Verwendung fortgeschrittener Techniken zur Bewegungskompensation vorteilhaft für eine hohe lokale Kontrolle sein mag [22,23], jedoch kann dies durch die technologischen und wissenschaftlichen Entwicklungen der letzten Jahre insgesamt überdeckt sein.…”

Section: Lokale Kontrolleunclassified

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Stereotaktische Strahlentherapie für Lebermetastasen

et al. 2019

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ZusammenfassungIn dieser Übersichtsarbeit wird der aktuelle Stand der stereotaktischen Strahlentherapie im Bereich des Körperstamms (SBRT) als Lokaltherapie für Patienten mit Lebermetastasen im Zustand der Oligometastasierung, Oligoprogression und Oligorekurrenz mit Fokus auf aktuelle Publikationen aus dem deutschsprachigen Raum dargelegt. Moderne SBRT-Techniken umfassen heute neben der präzisen Bildgebung auch Gating- und Tracking-Techniken, welche die Lokaltherapie von Lebermetastasen effektiver gemacht haben. Damit und mit zentralen Tumordosisoptimierungen lassen sich hohe lokale Kontrollraten von langfristig bis über 90% erreichen, die mit minimalen schweren Nebenwirkungsraten von unter 1% und 5-Jahres-Überlebensraten von mehr als 30% in selektionierten (inoperablen) Patientenkollektiven einhergehen. Durch hybride Ultraschall- oder MRT-Bestrahlungssysteme kann zukünftig die teils aktuell technisch erforderliche Fiducial-Marker-Implantation überwunden werden. Die SBRT stellt aufgrund der aktuellen Ergebnislage für Patienten mit Lebermetastasen eine wertvolle Ergänzung des therapeutischen Armamentariums als ebenbürtige Alternative zu minimalinvasiven ablativen Verfahren oder in Kombination mit anderen lokalen oder systemischen Behandlungen im interdisziplinären Kontext dar.

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Choosing a reference phase for a dynamic tumor tracking treatment: A new degree of freedom?

et al. 2019

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Purpose With the introduction of dynamic tumor tracking in radiotherapy, it is possible to irradiate moving targets with minimal safety margins. However, most dynamic tumor tracking techniques rely on changing the beam geometry by, for example, adapting the multileaf collimator (MLC) positions or rotating the LINAC head. These changes are relative to a reference position which is determined by a specific breathing phase. Since these changes in the beam path also influence the delivered dose, choosing a different reference position based on a different breathing phase impacts the applied dose to the patient. This work investigates the influence of choosing different reference breathing phases on the dose distribution. Methods The Vero system tracks the moving target by performing a pan and tilt rotation of the LINAC head. For 13 patients, the target position was extracted from every phase of a four‐dimensional computed tomography (4DCT) and the pan and tilt values were determined with respect to three different reference phases. These reference phases were inspiration, expiration, and the midventilation. For all reference phases, a 4D dose calculation was performed on the 4DCT regarding the respective pan and tilt values. Furthermore, the applied dose to the target and surrounding organs at risk was calculated. To accumulate the dose distribution, weights from the actual patient breathing motion were determined. The weights were calculated from the breathing motions from different days to investigate the impact of daily variations in the breathing motion onto the accumulated dose distribution. All obtained values were then compared to the static treatment plan. Results The mean and maximum doses applied to the target or surrounding organs at risk show no general behavior depending on the different reference phases. Nevertheless, for some patients, large differences (approx. 30%) in the applied dose to certain organs at risk could be observed, whereas the applied dose to the target shows no dependency on the different reference phases. However, the mean target dose is in all cases approx. 1.5% below the reference value from the static treatment plan. Conclusion Although no general dependency of the applied dose on the selected reference phase could be found, the choice of the reference phase can have great impact on the organ at risk dose for some patients. Thus, the choice of the reference phase used for patient positioning should be considered during treatment planning since it can be seen as a new degree of freedom of a treatment based on tracking.

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Breathing-motion-compensated robotic guided stereotactic body radiation therapy

Abstract: Robotic guided BMC-SBRT can be considered a safe and effective treatment for solid tumors in moving organs. To reach sufficient local control rates, high average GTV doses are necessary. Further prospective studies are warranted to evaluate these points.

Cited by 26 publications

References 47 publications

Stereotactic radiosurgery combined with immune checkpoint inhibitors or kinase inhibitors for patients with multiple brain metastases of malignant melanoma

Stereotactic radiosurgery combined with immune checkpoint inhibitors or kinase inhibitors for patients with multiple brain metastases of malignant melanoma

Stereotaktische Strahlentherapie für Lebermetastasen

Choosing a reference phase for a dynamic tumor tracking treatment: A new degree of freedom?

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