Judicious and evidence-based use of radiosurgery - recommendations for low-middle income countries.

Surgical removal remains the primary treatment for most brain tumours. However, radiosurgery presents an effective, less invasive alternative or additional treatment for certain types. Our goal was to explore radiosurgery's roles in treating various brain tumours, focussing on its application in low- and middle-income countries (LMICs). We reviewed all relevant systematic reviews, metaanalyses, and guidelines to determine the most effective radiosurgical approaches. Additionally, we consulted a panel of experts with over ten years of experience in LMICs, such as Pakistan. For brain tumours, stereotactic radiosurgery should generally follow a confirmed histopathological diagnosis. Exceptions include tumours identified through Magnetic Resonance Imaging (MRI), like Vestibular Schwannoma (VS), pre-diagnosed Neurofibromatosis type 2 (NF2), multiple typical meningiomas, and metastases with a known histology from another site. While radiosurgery is gaining traction as a primary and adjunct treatment in some LMICs, the lack of regional guidelines, trained personnel, and collaboration among specialists hinders its wider adoption. Addressing these gaps is crucial for expanding radiosurgical care in these regions.

Quality assurance for cancer patient safety: Clinical assessment for precise angles in linac during radiation therapy.

PURPOSE: Quality assurance for stereotactic body radiation treatment requires that isocentric verification be ensured during gantry rotation at various angles. This study examined statistical parameters on Winston-Lutz tests to distinguish the deviation of angles from isocenter during gantry rotation using machine learning. METHOD: The Varian TrueBeam linac was aligned with the marked lines on the Ruby phantom. Eight images were captured while the gantry was rotating at a 45° shift. The statistical features were derived from IsoCheck EPID software. The decision tree model was applied to these Winston-Lutz tests to cluster data into two groups: precise and error angles. RESULTS: At 90° and 270° angles, the gantry exhibits isocentric stability compared to other angles. In these angles, the most statistical features were inside the range. Most variations were observed at 0° and 180° angles. In most tests, the angles 45°, 135°, 225°, and 315° showed reasonable performance and with less variation. CONCLUSION: The comprehensive statistical analyses for gantry rotation of angles assists expert radiotherapists in determining the contribution of each feature that highly affects gantry movement at specific angles. Misalignment between radiation isocenter and imaging isocenter, tuning of the beam at each angle, or a slight change in the position of the Ruby phantom can further improve the inaccuracy that causes the most variations. Better precision can effectively increase patient safety and quality during cancer treatment.

Delphi consensus on stereotactic ablative radiotherapy for oligometastatic and oligoprogressive renal cell carcinoma-a European Society for Radiotherapy and Oncology study endorsed by the European Association of Urology.

The purpose of this European Society for Radiotherapy and Oncology (ESTRO) project, endorsed by the European Association of Urology, is to explore expert opinion on the management of patients with oligometastatic and oligoprogressive renal cell carcinoma by means of stereotactic ablative radiotherapy (SABR) on extracranial metastases, with the aim of developing consensus recommendations for patient selection, treatment doses, and concurrent systemic therapy. A questionnaire on SABR in oligometastatic renal cell carcinoma was prepared by a core group and reviewed by a panel of ten prominent experts in the field. The Delphi consensus methodology was applied, sending three rounds of questionnaires to clinicians identified as key opinion leaders in the field. At the end of the third round, participants were able to find consensus on eight of the 37 questions. Specifically, panellists agreed to apply no restrictions regarding age (25 [100%) of 25) and primary renal cell carcinoma histology (23 [92%] of 25) for SABR candidates, on the upper threshold of three lesions to offer ablative treatment in patients with oligoprogression, and on the concomitant administration of immune checkpoint inhibitor. SABR was indicated as the treatment modality of choice for renal cell carcinoma bone oligometatasis (20 [80%] of 25) and for adrenal oligometastases 22 (88%). No consensus or major agreement was reached regarding the appropriate schedule, but the majority of the poll (54%-58%) retained the every-other-day schedule as the optimal choice for all the investigated sites. The current ESTRO Delphi consensus might provide useful direction for the application of SABR in oligometastatic renal cell carcinoma and highlight the key areas of ongoing debate, perhaps directing future research efforts to close knowledge gaps.

Managing vestibular schwannomas with radiosurgery and radiotherapy: AGREE II appraisal of clinical practice guidelines.

INTRODUCTION: Vestibular schwannomas (VSs) are rare, benign intracranial tumours that have prompted clinical practice guideline (CPG) creation given their complex management. Our aim was to utilize the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess if such CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality. METHODS: Relevant CPGs were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. Experienced reviewers then extracted general CPG properties and rated their quality via the AGREE II instrument. Intraclass correlation coefficients (ICCs) were quantified to assess interrater reliability. RESULTS: Nine CPGs on the management of VSs with radiosurgery and radiotherapy were identified. All CPGs were created in the past six years and developed recommendations based on literature review and expert consensus. One guideline was deemed as high quality with seven others being moderate and one being low in quality. The clarity of the presentation domain had the highest mean scaled domain score of 96.0%. The domains of stakeholder involvement and applicability had the lowest means of 49.2% and 47.2%, respectively. ICCs were either good or excellent across all domains. CONCLUSION: Current CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality but would greatly benefit from improvements in applicability, stakeholder involvement, editorial independence and rigour of development. We recommend CPG authors reference the European Association of Neuro-Oncology (EANO) guideline as a developmental framework with the Congress of Neurological Surgeons/American Association of Neurological Surgeons (CNS/AANS) CPG being a valid alternative.

Stereotactic radiosurgery in India: A nationwide survey of technology and quality assurance practices.

PURPOSE: India is rapidly adopting advanced treatments like Stereotactic Radiosurgery (SRS). However, there is a paucity of data on SRS practice. The aim of study is to assess the current status of technology and practices of machine quality assurance (QA) and patient specific quality assurance for SRS in India. MATERIALS AND METHODS: A survey questionnaire was designed using Google Forms and sent to chief/senior medical physicists across 220 radiotherapy centers in India on July 15, 2022. It contained questions on infrastructure availability, treatment planning, and QA. RESULTS: SRS was found to be extensively used for the treatment of brain metastases (99.3%), followed by meningioma (50.3%), acoustic neuroma (45.5%), and pituitary tumours (33.1%). The most commonly used photon energy and treatment technique were 6MV FFF and VMAT, respectively. A prescription isodose line ranging from 70% to 100% was selected by linac users. Most linac institutes verify pretreatment doses. There was a lack of uniformity in the analysis metrics such as Low Dose Threshold, Dose Difference, and Distance to Agreement. A survey revealed that the variety of SRS QA programs being followed at Indian radiotherapy centers. CONCLUSION: This is the first study to report the physics practice of SRS in India. The survey shows a need to carry out a postal dose audit for small static photon fields in India.

Determination of Collimator Helmet Factors for Leksell Gamma Knife 4C Unit Using GAF Chromic EBT3 Film and ImageJ Software.

BACKGROUND: Measurement of Collimator helmet factors (CHF) is an important quality assurance procedure to be performed on Leksell Gamma Knife unit at regular interval to make sure that the interchangeable collimator helmet fit into the source channels without any positional inaccuracy which leads to major treatment error. The primary aim of this study is to measure the CHFs for Elekta Leksell Gamma knife 4C helmets using GafChromic EBT3 film and Image J software. METHODS: GafChromic EBT3 film, EPSON expression 10000 XL scanner and Image J analysis software was used for this study. The calibration curve of GafChromic EBT3 film was generated with known dose values for 14 mm collimator helmet using ImageJ software. The collimator helmet factor (CHF) for 4mm, 8mm and 14 mm collimator helmets were measured by normalizing dose rates of 4mm, 8mm and 14 mm to the dose rate of 18 mm collimator helmet using the previously generated calibration curve. The measured CHF was compared to Elekta reference value and previously published mean values. RESULTS: The measured CHFs were 0.896, 0.958, and 0.986 for 4mm, 8mm and 14mm collimators respectively. The percentage difference obtained was 1.7 %, 0.21 %, 0.1 % between measured values and reference values. CONCLUSION: The measurement of CHFs in LGK 4C unit using GafChromic EBT3 film and ImageJ software is a reliable method to verify the manufacturer quoted CHFs in routine quality assurance procedures.

Thoracic stereotactic body radiation therapy plus first-line tyrosine kinase inhibitors for patients with epidermal growth factor receptor-mutant polymetastatic non-small-cell lung cancer: A propensity-matched retrospective study.

ABSTRACT: The role of thoracic stereotactic body radiation therapy (SBRT) in addition to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in EGFR-mutant polymetastatic non-small-cell lung cancer (NSCLC) has not been well established. This retrospective study aimed to evaluate the efficacy and safety of EGFR-TKIs with thoracic SBRT for the treatment of this patient group.Polymetastatic NSCLC was defined as having >5 metastatic lesions. Patients with polymetastatic NSCLC harboring positive EGFR mutations after initial TKI therapy for at least 8 weeks were eligible for SBRT between August 2016and August 2019. Eligible patients were treated with thoracic SBRT, and TKIs were administered for the duration of SBRT and continued after SBRT until they were considered ineffective. The control group was treated with TKI monotherapy. Propensity score matching (ratio of 1:4) was used to account for differences in baseline characteristics. Progression-free survival (PFS), overall survival, and treatment safety were evaluated.In total, 136 patients were included in the study population. Among them, 120 patients received TKIs alone, and 16 patients received TKIs with thoracic SBRT. The baseline characteristics did not significantly differ between the two cohorts after propensity score matching. The median PFS was 17.8 months in the thoracic SBRT group and 10.8 months in the control group (P = .033). In the multivariate analysis, a Cox regression model showed that thoracic SBRT was an independent statistically significant positive predictor of improved survival, with a hazard ratio of 0.54 (P = .046). We recorded no severe toxic effects or grade 4 to 5 toxicities.Real-world data demonstrate that thoracic SBRT significantly extends PFS in EGFR-mutant polymetastatic NSCLC patients with tolerable toxicity. Given these results, randomized studies are warranted.

A priori quality assurance using a benchmark case of the randomized phase 2 GORTEC 2014-14 in oligometastatic head and neck cancer patients.

PURPOSE: A Benchmark Case (BC) was performed as part of the quality assurance process of the randomized phase 2 GORTEC 2014-14 OMET study, testing the possibility of multisite stereotactic radiation therapy (SBRT) alone in oligometastatic head and neck squamous cell carcinoma (HNSCC) as an alternative to systemic treatment and SBRT. MATERIAL AND METHODS: Compliance of the investigating centers with the prescription, delineation, planning and evaluation recommendations available in the research protocol was assessed. In addition, classical dosimetric analysis was supplemented by quantitative geometric analysis using conformation indices. RESULTS: Twenty centers participated in the BC analysis. Among them, four major deviations (MaD) were reported in two centers. Two (10%) centers in MaD had omitted the satellite tumor nodule and secondarily validated after revision. Their respective DICE indexes were 0.37 and 0 and use of extracranial SBRT devices suboptimal There were significant residual heterogeneities between participating centers, including those with a similar SBRT equipment, with impact of plan quality using standard indicators and geometric indices. CONCLUSION: A priori QA using a BC conditioning the participation of the clinical investigation centers showed deviations from good SBRT practice and led to the exclusion of one out of the twenty participating centers. The majority of centers have demonstrated rigorous compliance with the research protocol. The use of quality indexes adds a complementary approach to improve assessment of plan quality.

Quality Assurance for Small-Field VMAT SRS and Conventional-Field IMRT Using the Exradin W1 Scintillator.

BACKGROUND: Plastic scintillator detector (PSD) Exradin W1 has shown promising performance in small field dosimetry due to its water equivalence and small sensitive volume. However, few studies reported its capability in measuring fields of conventional sizes. Therefore, the purpose of this study is to assess the performance of W1 in measuring point dose of both conventional IMRT plans and VMAT SRS plans. METHODS: Forty-seven clinical plans (including 29 IMRT plans and 18 VMAT SRS plans with PTV volume less than 8 cm3) from our hospital were included in this study. W1 and Farmer-Type ionization chamber Exradin A19 were used in measuring IMRT plans, and W1 and microchamber Exradin A16 were used in measuring SRS plans. The agreement between the results of different types of detectors and TPS was evaluated. RESULTS: For IMRT plans, the average differences between measurements and TPS in high-dose regions were 0.27% ± 1.66% and 0.90% ± 1.78% (P = 0.056), and were -0.76% ± 1.47% and 0.37% ± 1.34% in low-dose regions (P = 0.000), for W1 and A19, respectively. For VMAT SRS plans, the average differences between measurements and TPS were -0.19% ± 0.96% and -0.59% ± 1.49% for W1 and A16 with no statistical difference (P = 0.231). CONCLUSION: W1 showed comparable performance with application-dedicated detectors in point dose measurements for both conventional IMRT and VMAT SRS techniques. It is a potential one-stop solution for general radiotherapy platforms that deliver both IMRT and SRS plans.

Operation and calibration of the novel PTW 1600SRS detector for the verification of single isocenter stereotactic radiosurgery treatments of multiple small brain metastases.

OBJECTIVES: The aim of this work was to evaluate the operation of the 1600SRS detector and to develop a calibration procedure for verifying the dose delivered by a single isocenter stereotactic radiosurgery (SRS) treatment of small multiple brain metastases (BM). METHODS: 14 clinical treatment cases were selected with the number of BM ranging from 2 to 11. The dosimetric agreement was investigated between the calculated and the measured dose by an OCTAVIUS 1600SRS array detector in an OCTAVIUS 4D phantom equipped with dedicated SRS top. The cross-calibration procedure deviated from the manufacturer's as it applied field sizes and dose rates corresponding to the volumetric modulated arc therapy segments in each plan. RESULTS: Measurements with a plan specific cross-calibration showed mean ± standard deviation (SD) agreement scores for cut-off values 50%, 80%, 95%, of 98.6 ± 1.7%, 96.5 ± 4.6%, 97.3 ± 4.4% for the 6 MV plans respectively, and 98.6 ± 1.5%, 96.6 ± 4.0% 96.4 ± 6.3%, for the 6 MV flattening filter free (FFF) plans respectively. Using the default calibration procedure instead of the plan specific calibration could lead to a combined systematic dose offset of 4.1% for our treatment plans. CONCLUSION: The 1600SRS detector array with the 4D phantom offers an accurate solution to perform routine quality assurance measurements of single isocenter SRS treatments of multiple BM. This work points out the necessity of an adapted cross-calibration procedure. ADVANCES IN KNOWLEDGE: A dedicated calibration procedure enables accurate dosimetry with the 1600SRS detector for small field single isocenter SRS treatment of multiple brain metastases for a large amount of BM.

Focus on the expected quality of reporting in SBRT/radiosurgery prospective studies: how far have we come in 30 years?

OBJECTIVES: We aimed at describing and assessing the quality of reporting in all published prospective trials about radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). METHODS: The Medline database was searched for. The reporting of study design, patients' and radiotherapy characteristics, previous and concurrent cancer treatments, acute and late toxicities and assessment of quality of life were collected. RESULTS: 114 articles - published between 1989 and 2019 - were analysed. 21 trials were randomised (18.4%). Randomisation information was unavailable in 59.6% of the publications. Data about randomisation, ITT analysis and whether the study was multicentre or not, had been significantly less reported during the 2010-2019 publication period than before (respectively 29.4% vs 57.4% (p < 0.001), 20.6% vs 57.4% (p < 0.001), 48.5% vs 68.1% (p < 0.001). 89.5% of the articles reported the number of included patients. Information about radiation total dose was available in 86% of cases and dose per fraction in 78.1%. Regarding the method of dose prescription, the prescription isodose was the most reported information (58.8%). The reporting of radiotherapy characteristics did not improve during the 2010 s-2019s. Acute and late high-grade toxicity was reported in 37.7 and 30.7%, respectively. Their reporting decreased in recent period, especially for all-grade late toxicities (p = 0.044). CONCLUSION: It seems necessary to meet stricter specifications to improve the quality of reporting. ADVANCES IN KNOWLEDGE: Our work results in one of the rare analyses of radiosurgery and SBRT publications. Literature must include necessary information to first, ensure treatments can be compared and reproduced and secondly, to permit to decide on new standards of care.

Optimal stereotactic body radiotherapy dosage for hepatocellular carcinoma: a multicenter study.

BACKGROUND: The optimal dose and fractionation scheme of stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) remains unclear due to different tolerated liver volumes and degrees of cirrhosis. In this study, we aimed to verify the dose-survival relationship to optimize dose selection for treatment of HCC. METHODS: This multicenter retrospective study included 602 patients with HCC, treated with SBRT between January 2011 and March 2017. The SBRT dosage was classified into high dose, moderate dose, and low dose levels: SaRT (BED10 ≥ 100 Gy), SbRT (EQD2 > 74 Gy to BED10 < 100 Gy), and ScRT (EQD2 < 74 Gy). Overall survival (OS), progression-free survival (PFS), local control (LC), and intrahepatic control (IC) were evaluated in univariable and multivariable analyses. RESULTS: The median tumor size was 5.6 cm (interquartile range [IQR] 1.1-21.0 cm). The median follow-up time was 50.0 months (IQR 6-100 months). High radiotherapy dose correlated with better outcomes. After classifying into the SaRT, SbRT, and ScRT groups, three notably different curves were obtained for long-term post-SBRT survival and intrahepatic control. On multivariate analysis, higher radiation dose was associated with improved OS, PFS, and intrahepatic control. CONCLUSIONS: If tolerated by normal tissue, we recommend SaRT (BED10 ≥ 100 Gy) as a first-line ablative dose or SbRT (EQD2 ≥ 74 Gy) as a second-line radical dose. Otherwise, ScRT (EQD2 < 74 Gy) is recommended as palliative irradiation.

Recommended procedures and responsibilities for radiosurgery (SRS) and extracranial stereotactic body radiotherapy (SBRT): report of the SEOR in collaboration with the SEFM.

Today, patient management generally requires a multidisciplinary approach. However, due to the growing knowledge base and increasing complexity of Medicine, clinical practice has become even more specialised. Radiation oncology is not immune to this trend towards subspecialisation, which is particularly evident in ablative radiotherapy techniques that require high dose fractions, such as stereotactic radiosurgery (SRS), and stereotactic body radiotherapy (SBRT). The aim of the present report is to establish the position of the Spanish Society of Radiation Oncology (SEOR), in collaboration with the Spanish Society of Medical Physics (SEFM), with regard to the roles and responsibilities of healthcare professionals involved in performing SRS and SBRT. The need for this white paper is motivated due to the recent changes in Spanish Legislation (Royal Decree [RD] 601/2019, October 18, 2019) governing the use and optimization of radiotherapy and radiological protection for medical exposure to ionizing radiation (article 11, points 4 and 5) [1 ], which states: "In radiotherapy treatment units, the specialist in Radiation Oncology will be responsible for determining the correct treatment indication, selecting target volumes, determining the clinical radiation parameters for each volume, directing and supervising treatment, preparing the final clinical report, reporting treatment outcomes, and monitoring the patient's clinical course." Consequently, the SEOR and SEFM have jointly prepared the present document to establish the roles and responsibilities for the specialists-radiation oncologists (RO), medical physicists (MP), and related staff -involved in treatments with ionizing radiation. We believe that it is important to clearly establish the responsibilities of each professional group and to clearly establish the professional competencies at each stage of the radiotherapy process.

Simultaneous Truth and Performance Level Estimation Method for Evaluation of Target Contouring in Radiosurgery.

BACKGROUND/AIM: The problem of lack of standardisation in target delineation and herewith the variability of target contours in Gamma Knife radiosurgery is as severe as in linac-based radiotherapy in general. The first aim of this study was to quantify the contouring variability for a group of five radiosurgery targets and estimate their true-volume based on multiple delineations using the Simultaneous Truth and Performance Level Estimation (STAPLE) algorithm. The second aim was to assess the robustness of the STAPLE method for the assessment of the true-volume, with respect to the number of contours available as input. PATIENTS AND METHODS: A multicentre analysis of the variability in contouring of five cases was performed. Twelve contours were provided for each case by experienced planners for Gamma Knife. To assess the robustness of the STAPLE method with respect to the number of contours used as input, sets of contours were randomly selected in the analysis. RESULTS: A high similarity was observed between the STAPLE generated true-volume and the 50%-agreement volume when all 12 available contours were used as input (90-100%). Lower similarity was observed with smaller sets of contours (10-70%). CONCLUSION: If a high number of input contours is available, the STAPLE method provides a valuable tool in the estimation of the true volume of a target based on multiple contours as well as the sensitivity and specificity for each input contour relative to the true volume of that structure. The robustness of the STAPLE method for rendering the true target volume depends on the number of contours provided as input and their variability with respect to shape, size and position.

Stereotactic Body Radiation Therapy for Spinal Metastases: Tumor Control Probability Analyses and Recommended Reporting Standards.

PURPOSE: We sought to investigate the tumor control probability (TCP) of spinal metastases treated with stereotactic body radiation therapy (SBRT) in 1 to 5 fractions. METHODS AND MATERIALS: PubMed-indexed articles from 1995 to 2018 were eligible for data extraction if they contained SBRT dosimetric details correlated with actuarial 2-year local tumor control rates. Logistic dose-response models of collected data were compared in terms of physical dose and 3-fraction equivalent dose. RESULTS: Data were extracted from 24 articles with 2619 spinal metastases. Physical dose TCP modeling of 2-year local tumor control from the single-fraction data were compared with data from 2 to 5 fractions, resulting in an estimated α/ß = 6 Gy, and this was used to pool data. Acknowledging the uncertainty intrinsic to the data extraction and modeling process, the 90% TCP corresponded to 20 Gy in 1 fraction, 28 Gy in 2 fractions, 33 Gy in 3 fractions, and (with extrapolation) 40 Gy in 5 fractions. The estimated TCP for common fractionation schemes was 82% at 18 Gy, 90% for 20 Gy, and 96% for 24 Gy in a single fraction, 82% for 24 Gy in 2 fractions, and 78% for 27 Gy in 3 fractions. CONCLUSIONS: Spinal SBRT with the most common fractionation schemes yields 2-year estimates of local control of 82% to 96%. Given the heterogeneity in the tumor control estimates extracted from the literature, with variability in reporting of dosimetry data and the definition of and statistical methods of reporting tumor control, care should be taken interpreting the resultant model-based estimates. Depending on the clinical intent, the improved TCP with higher dose regimens should be weighed against the potential risks for greater toxicity. We encourage future reports to provide full dosimetric data correlated with tumor local control to allow future efforts of modeling pooled data.

Stereotactic Radiosurgery for Vestibular Schwannomas: Tumor Control Probability Analyses and Recommended Reporting Standards.

PURPOSE: We sought to investigate the tumor control probability (TCP) of vestibular schwannomas after single-fraction stereotactic radiosurgery (SRS) or hypofractionated SRS over 2 to 5 fractions (fSRS). METHODS AND MATERIALS: Studies (PubMed indexed from 1993-2017) were eligible for data extraction if they contained dosimetric details of SRS/fSRS correlated with local tumor control. The rate of tumor control at 5 years (or at 3 years if 5-year data were not available) were collated. Poisson modeling estimated the TCP per equivalent dose in 2 Gy per fraction (EQD2) and in 1, 3, and 5 fractions. RESULTS: Data were extracted from 35 publications containing a total of 5162 patients. TCP modeling was limited by the absence of analyzable data of <11 Gy in a single-fraction, variability in definition of "tumor control," and by lack of significant increase in TCP for doses >12 Gy. Using linear-quadratic-based dose conversion, the 3- to 5-year TCP was estimated at 95% at an EQD2 of 25 Gy, corresponding to 1-, 3-, and 5-fraction doses of 13.8 Gy, 19.2 Gy, and 21.5 Gy, respectively. Single-fraction doses of 10 Gy, 11 Gy, 12 Gy, and 13 Gy predicted a TCP of 85.0%, 88.4%, 91.2%, and 93.5%, respectively. For fSRS, 18 Gy in 3 fractions (EQD2 of 23.0 Gy) and 25 Gy in 5 fractions (EQD2 of 30.2 Gy) corresponded to TCP of 93.6% and 97.2%. Overall, the quality of dosimetric reporting was poor; recommended reporting guidelines are presented. CONCLUSIONS: With current typical SRS doses of 12 Gy in 1 fraction, 18 Gy in 3 fractions, and 25 Gy in 5 fractions, 3- to 5-year TCP exceeds 91%. To improve pooled data analyses to optimize treatment outcomes for patients with vestibular schwannoma, future reports of SRS should include complete dosimetric details with well-defined tumor control and toxicity endpoints.

Extracranial dose and the risk of radiation-induced malignancy after intracranial stereotactic radiosurgery: is it time to establish a therapeutic reference level?

BACKGROUND: To measure extracranial doses from Gamma Knife Perfexion (GKP) intracranial stereotactic radiosurgery (SRS) and model the risk of malignancy after SRS for different treatment platforms. METHODS: Doses were measured for 20 patients undergoing SRS on a GKP at distances of 18, 43 and 75 cm from the target, corresponding to the approximate positions of the thyroid, breast and gonads respectively. A literature review was conducted to collect comparative data from other radiosurgery platforms. All data was used to calculate the dose to body organs. The National Cancer Institute (NCI) RadRAT calculator was used to estimate excess lifetime cancer risk from this exposure. Five different age groups covering childhood and younger adults were modelled for both sexes. RESULTS: Extracranial doses delivered during SRS with the GKP were a median 0.04%, 0.008% and 0.002% of prescription dose at 18 cm, 43 cm and 70 cm from the isocentre respectively. Comparison with the literature revealed that the extracranial dose was lowest from GKP, then linacs equipped with micro-multileaf collimators (mMLC), then linacs equipped with circular collimators (cones), and highest from Cyberknife (CK). Estimated lifetime risks of radiation-induced malignancy in the body for patients treated with SRS aged 5-45 years were 0.03-0.88%, 0.36-11%, 0.61-18% and 2.2-39% for GKP, mMLC, cones and CK respectively. CONCLUSIONS: We have compared typical extracranial doses from different platforms and quantified the lifetime risk of radiation-induced malignancy. The risk varies with platform. This should be taken into account when treating children and young adults with SRS. The concept of a therapeutic reference level (TRL), similar to the diagnostic reference level (DRL) established in radiology, is proposed.

[Revised guideline 'Brain metastases': More treatment options]. / Herziene richtlijn 'Hersenmetastasen'.

The guideline on brain metastasis from the Netherlands Society of Neurology has been updated. Important changes have been made, particularly with regard to treatment of brain metastases. Treatment of patients with brain metastases is complex and requires a multidisciplinary approach to formulate an optimal, individualized treatment plan. Neurosurgical resection may also be considered in patients with multiple brain metastases and one dominant, symptomatic lesion, if the patient is in good clinical condition. Stereotactic radiosurgery is a treatment option for patients with a maximum of 10 brain metastases, depending on the size and number of metastases. The indication for whole brain radiotherapy is relatively limited. Doctors should be cautious with whole brain radiotherapy in patients with a Karnofsky Performance Status <70. In patients with small, asymptomatic brain metastases, targeted therapy or immune therapy may be considered without locoregional therapy.