Upload
duttaradio
View
17
Download
2
Tags:
Embed Size (px)
Citation preview
Small AVMs need treatment with either surgery or radiosurgery
Deep seated & eloquent area AVMs need radiosurgery treatment
Radiosurgery is single fraction, usually dose more than 18 Gy to the nidus
Obliteration rate (cure rate) is 70-80% at 2-year evaluation
Gammaknife / Linac based systems: need invasive frame
Cyberknife: No need for invasive frame
Out-patient procedure, excellent compliance
Obliteration rate is similar to frame based systems
Arteriovenous malformation
Radiosurgery experience in AVMsAuthor (yr) Pt No FU (yr) Ave Dose
(Gy)Obiteration rate (%)
Complications
Flickinger et al 1987-1997
351 4.2 20 75 Necrosis, neurological deficits
French Dose Response study
100 5 20 708 pts had delayed complications
Pollock et al 144 2 20 73 20 pts had neurological deficit
AVM<3 cm; SM Gr I-IIIAt 2 yr FU with DSA: Obliteration rate is 70-80%Persistent Neurological deficit: <9%
Author (yr) Pt No
FU (yr)
Vol Ave Dose (Gy)
Obiteration rate (%)
Complications
Jalali et al TMH
87 2 3.65 20 92 1pt had temporary neurological deficit
Kiran et alAIIMS
308 2 4.3 20 74 8 pts developed radiation edema
Patel GCRI 2008
16 2 - 16 75 1 pt hd hemorrhage, 1 pt hd necrosis
Radiosurgery experience in AVMs from India
Only few prospective studies from India on AVM with SRS
Three studies showing at per obliteration rate & toxicity as western literature
SRS is feasible in our set [email protected]
Rigid frame based SRS: Work Flow
Fixation of frame
DSA
CT Scan
Image fusion
Planning
QA (LUTZ test)
Treatment
One day procedureNeed admission of patientFrame fixed >6-8 hours
Jalali, Dutta et al. J Cancer Res Ther, 2009
Min Max Mean SD
Nidus Volume (cc) 1.1 5.6 3.6 1.6
Marginal dose (Gy) 14.4 25 19.2 3.2
12 Gy normal brain vol (cc) 3.3 15.3 8.3 4.2
Maximum dose (Gy) 16 27.5 22 3.7
12 Gy marginal volume (cc) 0.3 9.6 5 4.4
Isodose Coverage (%) 80 91 87.5 3.3
Optic Chiasm dose (Gy) 0.5 0.5 0.4 0.01
Brainstem dose (Gy) 0.5 6 2.5 2.5
(n=23)
Nidus Vol: 3.6 ccMean marginal dose: 19.2 (14.4-25 Gy)
Follow up (mo) Mean
24.3 (1.57 to 71.2)
Median 22 Number of patient referred for SRS 87Number of patients planned for SRS 23 Number of patients treated with SRS 21
LFU status clinical examination No deficits 22 Neurological deficit persists after 2 yr FU 01Type of Imaging done for Assessment
MRI and MRA done at 2 yrs FU 15DSA 12
Imaging awaited on follow up 06Last Follow up status on Imaging
MRA proven obliteration 15 Obliteration confirmed on DSA 11
No Obliteration on DSA 01Complication after SRS
No complication 18Temporary worsening 02
Persistent neurological deficit 01
Follow up & obliteration rate
Obliteration rate at 2 yr follow up DSA: 92%
Median FU: 22 moObliteration rate: 92%Persistent Deficit: 1 pt
Rigid frame (screw) based radiosurgery
Issues with frame fixationPain & hematomaFixed frame: 6-8 hoursOne day procedure
Primary aim of the study:Evaluation of obliteration rate at 1 yearSecondary aim:Complication rateEvaluation of dose distribution parameters Evaluation of factors influencing obliteration rate
Title: Robotic -based stereotactic radiosurgery for selected AVMs: preliminary experience from Apollo Hospital, Chennai
Study type: Prospective observational study (DNB dissertation)
Study duration: 3 years (Initial data presented here)
Pt number: 30 (Accrued till date)Institute: Apollo Speciality Hospital, Chennai
Study design: Frameless Robotic SRS in AVM
Eligibility Criteria Radiologically confirmed AVMs in brain.Spetzler Martin grade I-IIINidus size <4 cmHistory of prior hemorrhage, headache, tinnitus or convulsion.Willing for robotic radiosurgery treatment
Ineligibility criteriaActive haemorhageLarge AVMs (>5 cm nidus)Presence of aneurysm or AV shuntingPresence of calcification and intranidal fistulaPrevious radiation (n=30)
Study design: Frameless Robotic SRS in AVMTitle: Robotic -based stereotactic radiosurgery for selected AVMs: preliminary experience from Apollo Hospital, Chennai
30 pts willing for Robotic SRS fulfilling the criteria accrued from Oct 2011 & have
more than 6 month FU were accrued for analysis
Site distribution: 14 in temporo-parietal region, 10 in frontal, 4 had intraventricular ,
1 in thalamic and 1 in cerebellar region .
Planning CT, CT angiogram, MRI, MR angiogram with 1 mm slice thickness.
Fusion and planning with Multiplan, Accuray system
Dose prescription was considered according to the flickenger’s model keeping
obliteration rate >80% & severe neurological toxicity <2%
6Dskull tracking .
Study design: Frameless Robotic SRS in AVM
(n=30)[email protected]
Frameless SRS: Work Flow
Thermoplastic mask
CT AngioMR AngioCT Scan
Image fusionPlanning
QA
2 days procedureOUT PATIENTNo admission of patientTreatment with mask
Next day:
Day 1:
Planning: Frameless Robotic SRS in AVM
(n=30)
Treatment delivery: Frameless Robotic SRS in AVM
Treatment time: 20-45 minThermoplast based SRSPts received Dexa/ PPINo acute toxicity for majority of patients (one pt had brain oedema requiring MDT)
Age (yr) mean (SD) 31.13 YRS
Range 6- 60 YRSGender male 17
Female 13
Duration of symptoms (mo) Mean5.8
Range1-60
Primary presenting symptoms
Headache alone 12 (40%)
Convulsions alone6(20%)
Neurological deficit alone3(10%)
Headache and neurodeficit1(3%)
Headache and convulsion8(27%)
Location TP region 14
Frontal10
Intraventricular region4
Thalamic1
Cerebellar 1
Demographic profiles: Frameless Robotic SRS in AVM
AVM size <1cm 0
1-2 cm 22- 3 cm 183 - 4 cm 10
SM grade
I-II18
III 12
Previous H’hge 12
Previous neurodeficit3
(n=30)
Nidus Vol: 2.97 cc
Marginal dose:17.5 Gy (15-22 Gy)
Isodose prescription: 85%(80-90%)
Treatment time: 35 min (23-70 min
Dosimetric profile Min Max Mean
Nidus volume (cc) 0.46 7.7 2.97
Max dose (Gy) 15 22 17.5
Isodose coverage (% ) 80 90 85
Optic chiasm dose (cGy) 4 760 280
Rt eye dose (cGy) 3 448 146
Lt eye dose (cGy) 4 719 108
Beam lets 56 165 107
Treatment time (min) 23 70 35
HI 1.09 1.25 1.17
(n=30)
Dosimetric parameters: Frameless Robotic SRS in AVM
Follow up duration(in months)
Mean* 14
Median 6-30
Pt condition on last followup
Normal* 18
Deficits
Nil
Type of imaging
MR angio at 6 months 30
MR angio at 12 months 16
MR Angio obliteration more than 1 yr follow up
Complete obliteration 13
Reduction in nidus volume 3
OUTCOMEMR ANGIO >1 YR - 16 ptCOMPLETE OBLITERATION - 13 pt (81%)
(n=30)
Results: Frameless Robotic SRS in AVM
Follow up: 14 monthsMedian Dose: 18 GyObliteration rate: 81%No Persistent Neurological deficit
Framebased versus Frameless SRS in AVM
Frame based
Frameless
Rigid FrameFrame Fixed: 4-8 hrsPain/ HematomaAdmission
Thermoplastic maskMask with pt: <30 minNo Pain/ HematomaOut-patient
Framebased versus Frameless SRS in AVMProblems with Screws
Pain / HematomaCompliance issueLong duration fixed frame (4-8 hrs)
‘Quality of life’ issue
Subdural hematoma 10%
Framebased versus Frameless SRS in AVM
Frame based
Frameless
Dosimetry & treatment parameters
Nidus Vol: 3.6 ccMean marginal dose: 19.2 (14.4-25 Gy)Frame fixed 4-8 hrs
Nidus Vol: 2.97 cc
Marginal dose:17.5 Gy (15-22 Gy)
Isodose prescription: 85%(80-90%)
Treatment time: 35 min (23-70 [email protected]
Framebased versus Frameless SRS in AVM
Frame based
Frameless
N=23Median FU: 22 moMedian does: 19.2 GyObliteration rate: 92%Persistent Deficit: 1 pt
N=16Median FU: 14 monthsMedian Dose: 18 GyObliteration rate: 81%No Persistent Neurological deficit
Obliteration rate & Toxicity
Frame based versus Frameless SRS in AVM
- It seems, Obliteration rate in both frame based & frameless almost similar
- In frame based system, frame usually used for 4-8 hrs & frameless system only 30-45 min
- Compliance higher with frameless, out-patient treatment
- ‘Early quality of life’ better with frameless
- In Multiplan planning system dosimetric parameters exciting [email protected]
Flickinger et al.. Rad Onc 2002; 63:347-354.
Flickinger model
Dose prescription (Isocentre)
Marginal dose ( Gy)
12 Gy normal brain vol (cc)
Obliteration:Depends upon marginal dose
Complication:Depends upon 12 Gy normal brain vol
Beam reduction effect on 12 Gy Normal brain Vol
Optimum plan after approval taken for study
Marginal dose: 22 Gy; Pres Isodose: 85%Coverage: 99.5%Nidus size: 2.5 cmNidus Vol: 5.2 cc12 Gy Normal Brain Vol: 22.5 cc
Beams: 85Total MU:14414Min MU: 15 Max MU: 622
Beam reduction done by reducing beams with minimum MU in steps of 50, 100, 150, 200, 250 MU Collimator size kept same
Prescription Isodose changes to keep Nidus coverage >99%[email protected]
0 50 100 150 200 250
8579
59
51
3326
Beam reduction effect on 12 Gy Normal brain Vol
No of Beams
Beam reduction in steps of 50 MU
Increasing the beamlets MU cutoff limit reduce low MU beams [email protected]
85 79 59 51 33 26 23 22 21 20
CI 1.67 1.67 1.85 1.78 3.12 3.54 3.75 3.96 3.83 3.7
nCI 1.69 1.69 1.86 1.79 3.14 3.57 3.77 3.99 3.87 3.73
HI 1.18 1.18 1.2 1.2 1.72 1.85 1.92 2 2 2
0.25
0.75
1.25
1.75
2.25
2.75
3.25
3.75
4.25C
I /
nC
I /
HI
MU 14106 14190 14512 14189 16500 17523 17171 18558 17621 17299
Coverage (%) 99 99.1 99.3 99.1 99.2 99.2 99.3 99.2 99.2 99.1Pres Isodose 85 85 83 83 58 54 52 50 50 5012Gy Vol 23.5 26.4 27.5 25.8 36.6 39.9 44.6 45 45.4 46.8
Beam reduction effect on 12 Gy Normal brain Vol
85 79 59 51 33 26 23 22 21 20
23.526.4 27.5
25.8
36.6
39.9
44.6 45 45.4 46.8
12Gy Normal brain Vol (cc)
0 50 100 150 200 250
85
79
59
51
33
26
No of Beams
85 79 59 51 33 26
Beam reduction effect
Beam reduction effect on 12 Gy Normal brain Vol
Beams
Correlation Coefficient: 95.6% p-value: 0.003
Pearson correlation [email protected]
Beam reduction effect: Neurodeficit probability
85 79 59 51 45 33 26 22 210
5
10
15
20
25
30
35
40Occip-italFrontalParital
Pers
isten
t Neu
rolo
gica
l def
icit p
roba
bility
(%)
Beam numbers
20-50% increase in PND with beam reduction
According to Flickinger et al.. Rad Onc 2002; 63:347-354.
Nidus Diameter
Coverage (%)
Pres Isodose CI
2.5 cm 99 85 1.673.5 cm 99.4 77 1.354.5 cm 99.9 73 1.3
Effect of increased nidus vol on 12Gy Normal brain Vol
Nidus size: 2.5 cmNidus Vol: 5.2 ccMarginal dose: 22 GyCoverage: 99.5%Presription Isodose: 85%
0.5 cm margin to NidusNidus diameter: 3.5 cm
1 cm margin to NidusNidus diameter: 4.5 cm
Marginal dose: 22 GyCoverage >99%
Change CollimeterChange prescription Isodose
Evaluate 12Gy Normal brain Vol
PTV2.5
PTV3.5
PTV4.5
Nidus Diameter Beams
Correlation Coeff p-value
12Gy Vol (cc)
Correlation Coeff p-value
2.5 cm 8599.6 0.003
23.593.4 0.0523.5 cm 167 63.6
4.5 cm 227 247
Series1
85
167
227
2.5 cm Nidus
3.5 cmNidus
4.5 cm Nidus
p-value: 0.003
Series1
23.5
63.6
247
2.5 cm Nidus
4.5 cm Nidus
p-value: 0.052
3.5 cmNidus
No of Beams 12Gy Normal Brain Vol (cc)
Impact of larger nidus
Obliteration rate: It seems, Frameless SRS system is similar to frame based
systems
Frameless system: Compliance is excellent, out-patient procedure
Multiple beamlets may have dosimetric advantages with lesser 12 Gy normal
brain volume and acceptable marginal dose
‘Quality of life’ and acceptance by patient is excellent with frameless system
AVM- Conclusions