Dianne Hartgerink1, Ans Swinnen1, David Roberge2, Alan Nichol2, Piotr Zygmanski3, Fang-Fang Yin4, François Deblois2, Coen Hurkmans5, Chin Loon Ong6, Anna Bruynzeel7, Ayal Aizer3, John Fiveash8, John Kirckpatrick3, Matthias Guckenberger9, Nicolaus Andratschke9, Dirk de Ruysscher1, Richard Popple8, Jaap Zindler1,10,11. 1. Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center , Maastricht , The Netherlands. 2. Department of Radiation Oncology, CHUM , Montreal , QC , Canada. 3. Brigham and Women's Hospital, Dana Farber Cancer Institute and Harvard Medical School , Boston , Massachusetts , USA. 4. Department of Radiation Oncology, Duke University Medical Center , Durham , North Carolina , USA. 5. Department of Radiation Oncology, Catharina Hospital , Eindhoven , The Netherlands. 6. Department of Radiation Oncology, HagaZiekenhuis , Den Haag , The Netherlands. 7. Department of Radiotherapy, Cancer Center Amsterdam, VU University medical center , Amsterdam , The Netherlands. 8. Department of Radiation Oncology, University of Alabama at Birmingham , Birmingham , Alabama , USA. 9. Department of Radiation Oncology, University Hospital Zürich , Zürich , Switzerland. 10. Department of Radiation Oncology, Erasmus MC , Rotterdam , The Netherlands. 11. Holland Proton Therapy Center , Delft , The Netherlands.
Abstract
Introduction: Stereotactic radiosurgery (SRS) is a promising treatment option for patients with multiple brain metastases (BM). Recent technical advances have made LINAC based SRS a patient friendly technique, allowing for accurate patient positioning and a short treatment time. Since SRS is increasingly being used for patients with multiple BM, it remains essential that SRS be performed with the highest achievable quality in order to prevent unnecessary complications such as radionecrosis. The purpose of this article is to provide guidance for high-quality LINAC based SRS for patients with BM, with a focus on single isocenter non-coplanar volumetric modulated arc therapy (VMAT). Methods: The article is based on a consensus statement by the study coordinators and medical physicists of four trials which investigated whether patients with multiple BM are better palliated with SRS instead of whole brain radiotherapy (WBRT): A European trial (NCT02353000), two American trials and a Canadian CCTG lead intergroup trial (CE.7). This manuscript summarizes the quality assurance measures concerning imaging, planning and delivery. Results: To optimize the treatment, the interval between the planning-MRI (gadolinium contrast-enhanced, maximum slice thickness of 1.5 mm) and treatment should be kept as short as possible (< two weeks). The BM are contoured based on the planning-MRI, fused with the planning-CT. GTV-PTV margins are minimized or even avoided when possible. To maximize efficiency, the preferable technique is single isocenter (non-)coplanar VMAT, which delivers high doses to the target with maximal sparing of the organs at risk. The use of flattening filter free photon beams ensures a lower peripheral dose and shortens the treatment time. To bench mark SRS treatment plan quality, it is advisable to compare treatment plans between hospitals. Conclusion: This paper provides guidance for quality assurance and optimization of treatment delivery for LINAC-based radiosurgery for patients with multiple BM.
Introduction: Stereotactic radiosurgery (SRS) is a promising treatment option for patients with multiple brain metastases (BM). Recent technical advances have made LINAC based SRS a patient friendly technique, allowing for accurate patient positioning and a short treatment time. Since SRS is increasingly being used for patients with multiple BM, it remains essential that SRS be performed with the highest achievable quality in order to prevent unnecessary complications such as radionecrosis. The purpose of this article is to provide guidance for high-quality LINAC based SRS for patients with BM, with a focus on single isocenter non-coplanar volumetric modulated arc therapy (VMAT). Methods: The article is based on a consensus statement by the study coordinators and medical physicists of four trials which investigated whether patients with multiple BM are better palliated with SRS instead of whole brain radiotherapy (WBRT): A European trial (NCT02353000), two American trials and a Canadian CCTG lead intergroup trial (CE.7). This manuscript summarizes the quality assurance measures concerning imaging, planning and delivery. Results: To optimize the treatment, the interval between the planning-MRI (gadolinium contrast-enhanced, maximum slice thickness of 1.5 mm) and treatment should be kept as short as possible (< two weeks). The BM are contoured based on the planning-MRI, fused with the planning-CT. GTV-PTV margins are minimized or even avoided when possible. To maximize efficiency, the preferable technique is single isocenter (non-)coplanar VMAT, which delivers high doses to the target with maximal sparing of the organs at risk. The use of flattening filter free photon beams ensures a lower peripheral dose and shortens the treatment time. To bench mark SRS treatment plan quality, it is advisable to compare treatment plans between hospitals. Conclusion: This paper provides guidance for quality assurance and optimization of treatment delivery for LINAC-based radiosurgery for patients with multiple BM.
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