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Utilisation of Diffusion Tensor Imaging in Intracranial Radiotherapy and Radiosurgery Planning for White Matter Dose Optimization: A Systematic Review

Yahya N, Manan HA

World Neurosurg, 2019 Oct;130:e188-e198.
PMID: 31326352 DOI: 10.1016/j.wneu.2019.06.027

BACKGROUND: Diffusion tensor imaging (DTI), which visualizes white matter tracts, can be integrated to optimize intracranial radiation therapy (RT) and radiosurgery (RS) treatment planning. This study aimed to systematically review the integration of DTI for dose optimization in terms of evidence of dose improvement, clinical parameter changes, and clinical outcome in RT/RS treatment planning.
METHODS: PubMed and Scopus electronic databases were searched based on the guidelines established by PRISMA to obtain studies investigating the integration of DTI in intracranial RT/RS treatment planning. References and citations from Google Scholar were also extracted. Eligible studies were extracted for information on changes in dose distribution, treatment parameters, and outcome after DTI integration.
RESULTS: Eighteen studies were selected for inclusion with 406 patients (median study size, 19; range: 2-144). Dose distribution, with or without DTI integration, described changes of treatment parameters, and the reported outcome of treatment were compared in 12, 7, and 10 studies, respectively. Dose distributions after DTI integration improved in all studies. Delivery time or monitor unit was higher after integration. In studies with long-term follow-up (median, >12 months), neurologic deficits were significantly fewer in patients with DTI integration.
CONCLUSIONS: Integrating DTI into RT/RS treatment planning improved dose distribution, with higher treatment delivery time or monitor unit as a potential drawback. Fewer neurologic deficits were found with DTI integration.

Matched MeSH terms: Brain Neoplasms/radiotherapy
Fulltext LINAC based radiosurgery and radiotherapy for neurosurgical diseases: what have we learnt so far

Zamzuri I, Badrisyah I, Rahman GI, Pal HK, Muzaimi M, Jafri AM, et al.

Med J Malaysia, 2011 Oct;66(4):346-9.
PMID: 22299555 MyJurnal

Stereotactic radiosurgery uses a single fraction high dose radiation while stereotactic radiotherapy uses multifractionated lower dose focused radiation.

Matched MeSH terms: Brain Neoplasms/radiotherapy*
Fulltext Early Malaysian experience on the use of head and neck localizers in the precision radiotherapy of intra and extra cranial sites for first 28 cases

Zamzuri I, Idris NR, Mar W, Abdullah JM, Zakaria A, Biswal BM

Med J Malaysia, 2006 Dec;61(5):621-5.
PMID: 17623965 MyJurnal

Precision Radiotherapy at high doses require a fixed, referable target point. The frame system fulfills the required criteria by making the target point relocatable and fixed within a stereotactic space. Since December 2001, we have treated 28 central and peripheral nervous system lesions using either radiosurgery as a single high dose fraction or fractionated 3-dimensional conformal radiotherapy using a lower dose and a multi-leaf collimator. Various pathological lesions either benign or malignant were treated. Eighty six percent of our treated lesions showed growth restraint, preventing them from causing new symptoms with a median follow-up duration of 20.5 months. However, the true benefit from this technique would require a long-term follow-up to document the progress.

Matched MeSH terms: Brain Neoplasms/radiotherapy*
Hippocampal Sparing Whole Brain Radiotherapy and Integrated Simultaneous Boost vs Stereotactic Radiosurgery Boost: A Comparative Dosimetric Planning Study

Cheah SK, Matthews T, Teh BS

Asian Pac J Cancer Prev, 2016;17(9):4233-4235.
PMID: 27797223

BACKGROUND: Whole brain radiotherapy (WBRT) and stereotactic radiosurgery were frequently used to palliate patients with brain metastases. It remains controversial which modality or combination of therapy is superior especially in the setting of limited number of brain metastases. The availability of newer medical therapy that improves survival highlighted the importance of reducing long term radiation toxicity associated with WBRT. In this study, we aim to demonstrate the hippocampal sparing technique with whole brain and integrated simultaneous boost Materials and Methods: Planning data from 10 patients with 1-5 brain metastases treated with SRS were identified. Based on the contouring guideline from RTOG atlas, we identified and contoured the hippocampus with 5mm isocentric expansion to form the hippocampal avoidance structure. The plan was to deliver hippocampal sparing whole brain radiotherapy (HSWBRT) of 30 Gy in 10 fractions and simultaneous boost to metastatic lesions of 30 Gy in 10 fractions each.
RESULTS: The PTV, hippocampus and hippocampal avoidance volumes ranges between 1.00 - 39.00 cc., 2.50 - 5.30 cc and 26.47 - 36.30 cc respectively. The mean hippocampus dose for the HSWBRT and HSWBRT and SIB plans was 8.06 Gy and 12.47 respectively. The max dose of optic nerve, optic chiasm and brainstem were kept below acceptable range of 37.5 Gy.
CONCLUSIONS: The findings from this dosimetric study demonstrated the feasibility and safety of treating limited brain metastases with HSWBRT and SIB. It is possible to achieve the best of both worlds by combining HSWBRT and SIB to achieve maximal local intracranial control while maintaining as low a dose as possible to the hippocampus thereby preserving memory and quality of life.

Matched MeSH terms: Brain Neoplasms/radiotherapy*
Fulltext Intracranial germinoma metastasizing via a ventriculo-peritoneal shunt

Wong KT, Koh KB, Lee SH, Chee CP

Singapore Med J, 1996 Aug;37(4):441-2.
PMID: 8993152

Primary germinomas of the central nervous system carry a good prognosis because of their radiosensitivity. Recurrences are rare and extraneural metastases are even more unusual. One of the possible routes of extraneural spread is via ventriculo-peritoneal shunts which may be required to reduce intracranial pressure. One such case of germinoma metastasizing via a ventriculo-peritoneal shunt is reported. Patients with intracranial germinomas and ventriculo-peritoneal shunts should have close surveillance of their abdomens and may require systemic chemotherapy.

Matched MeSH terms: Brain Neoplasms/radiotherapy
Fulltext Visual epilepsy in glioblastoma multiforme

Chong PK, Loo AV

Med J Malaysia, 2008 Dec;63(5):406-7.
PMID: 19803301 MyJurnal

We report a 33-year-old Chinese gentleman who presented with visual epilepsy and symptoms of raised intracranial pressure in which clinical examination revealed normal visual fields and acuity despite Magnetic Resonance Imaging (MRI) brain showing large contrast enhancing mass at the right occipital lobe. Craniotomy and excision of tumour was done and the histology confirmed glioblastoma multiforme (GBM). He completed radiotherapy and recovered well except developing left inferior homonymous quadrantropia post operatively which improved with time.

Matched MeSH terms: Brain Neoplasms/radiotherapy
Prognostic factors in patients with non-small cell lung carcinoma and brain metastases: a Malaysian perspective

Tang WH, Alip A, Saad M, Phua VC, Chandran H, Tan YH, et al.

Asian Pac J Cancer Prev, 2015;16(5):1901-6.
PMID: 25773842

BACKGROUND: Brain metastases occur in about 20-40% of patients with non-small-cell lung carcinoma (NSCLC), and are usually associated with a poor outcome. Whole brain radiotherapy (WBRT) is widely used but increasingly, more aggressive local treatments such as surgery or stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) are being employed. In our study we aimed to describe the various factors affecting outcomes in NSCLC patients receiving local therapy for brain metastases.
MATERIALS AND METHODS: The case records of 125 patients with NSCLC and brain metastases consecutively treated with radiotherapy at two tertiary centres from January 2006 to June 2012 were analysed for patient, tumour and treatment-related prognostic factors. Patients receiving SRS/SRT were treated using Cyberknife. Variables were examined in univariate and multivariate testing.
RESULTS: Overall median survival was 3.4 months (95%CI: 1.7-5.1). Median survival for patients with multiple metastases receiving WBRT was 1.5 months, 1-3 metastases receiving WBRT was 3.6 months and 1-3 metastases receiving surgery or SRS/SRT was 8.9 months. ECOG score (≤2 vs >2, p=0.001), presence of seizure (yes versus no, p=0.031), treatment modality according to number of brain metastases (1-3 metastases+surgery or SRS/SRT±WBRT vs 1-3 metastases+WBRT only vs multiple metastases+WBRT only, p=0.007) and the use of post-therapy systemic treatment (yes versus no, p=0.001) emerged as significant on univariate analysis. All four factors remained statistically significant on multivariate analysis.
CONCLUSIONS: ECOG ≤2, presence of seizures, oligometastatic disease treated with aggressive local therapy (surgery or SRS/SRT) and the use of post-therapy systemic treatment are favourable prognostic factors in NSCLC patients with brain metastases.

Matched MeSH terms: Brain Neoplasms/radiotherapy*