Amelia glioblastoma
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Transcript of Amelia glioblastoma
The Role of External Beam Radiation Therapy
Brain, Spinal cord, Meninges Primary or Metastatic Metastatic cancers of the CNS are more
common Types of CNS tumours:
Gliomas Spinal cord tumours Intracranial germ cell tumours
Figure 1. The brain and spinal cord of the CNShttp://www.encognitive.com/node/1115
Figure 2. Frequency of all primary CNS gliomas. Adamson, C., et al. (2009) Glioblastoma multiforme: A review of where we have been and where we are going. Expert Opinion on Investigational Drugs, 18(8): 1061-1083
Extensive microvascular infiltration Rapid proliferation High rates of recurrence Presenting features:
Seizures Headaches Focal neurologic deficits
Etiology unknown
Diagnostic workup Patient history and physical examination Magnetic Resonance Imaging (MRI) Contrast-enhanced CT Biopsy – pathologic confirmation
Staged according to the World Health Organisation (WHO) classification system
Table 1. WHO classification system for CNS tumours
Figure 3. Treatment management approach for glioblastoma
External beam vs. Stereotactic, Brachytherapy, Hyperfractionation, Radioenhancers, BCNT, Accelerated, Dose escalation
3DCRT vs. IMRT vs. Rapidarc
Table 2. Recommended techniques for malignant glioma planning and their respective advantages and disadvantages. Wagner, D. et al. (2009) Radiotherapy of malignant gliomas: Comparison of volumetric single arc technique (Rapidarc), dynamic intensity-modulated technique and 3D conformal technique. Radiotherapy and Oncology, 93:593-596
SupineThermoplastic
immobilization mask
CT with intravenous contrast
Figure 4. Contrast enhanced CT of brain. Arrow indicates GBM multiforme. Drislane, F. et al. (2006) Chapter 19: Brain Tumors. Blueprints Neurology, Philadelphia: Lippincott Williams & Wilkins
Post-op MRI scan + CT fusion Target volume: 2-3cm margin around
contrast-enhanced lesion Whole brain radiotherapy
Multifocal gliomas Gliomas crossing midline or involving both
hemispheres
Figure 5. (A) Target delineation of a GBM. GTV outlined in blue. CTV with an additional 2cm margin to cover microscopic disease is represented by the green line. An additional 0.5cm margin is added to create the PTV for daily setup variability. (B) 3 field 3DCRT planned treatment for the same patient. Preusser, M. et al. (2011) Current concepts and management of glioblastoma. Annals of Neurology, 70: 9-21
Recommendations for 2-6 weeks post-surgery
Treatment position same as in simulation Immobilisation mask accuracy within order of
5mm Appropriate QA procedures and treatment
verification carried out 2D-2D matching IGRT can reduce PTV margin to
3mm Dependent on available imaging modalities at
each centre
Patients with GBM have a relatively poor prognosis and much research is needed in the way of improved treatment standards, especially to do with recurrent GBM
Requires MDT approach for treatment Care must be taken in the planning of GBM
Be aware of proximity of OAR, need for partial or whole brain RT and the advantages/disadvantages of different EBRT techniques which may assist in planning
If performing IMRT or Rapidarc, additional QA measure must be taken
Be aware of associated side effects and flag to appropriate member of MDT if thought necessary
http://www.encognitive.com/node/1115 Adamson, C., et al. (2009) Glioblastoma multiforme: A review of where we have been and where we are going. Expert Opinion on Investigational
Drugs, 18(8): 1061-1083 Al-Mohammed, H.I. (2011) Patient specific quality assurance for glioblastoma multiforme brain tumours treated with intensity modulated radiation
therapy. International Journal of Medical Sciences, 8(6): 461-466 Amelio, D. et al. (2010) Intensity-modulated radiation therapy in newly diagnosed glioblastoma: A systematic review on clinical and technical issues.
Radiotherapy and Oncology, 97: 361-369 Barrett, A. et al. (2009) Chapter 4: Organs at risk and tolerance of normal tissues. Practical Radiotherapy Planning, London: Hodder Arnold Brandes, A.A. et al. (2008) Glioblastoma in adults. Critical Reviews in Oncology/Hematology, 67: 139-152 Drislane, F. et al. (2006) Chapter 19: Brain Tumors. Blueprints Neurology, Philadelphia: Lippincott Williams & Wilkins Fiveash, J.B. & Spencer, S.A. (2005) Role of radiation therapy and radiosurgery in glioblastoma multiforme. Glioblastoma Multiforme, Massachusetts:
Jones and Bartlett Publishers Greene, F.L. et al. (2002) Chapter 47: Brain and spinal cord. AJCC Cancer Staging Handbook, New York: Springer Hansen, E.K. & Roach III, M. (2010) Part II: Central nervous system. Handbook of Evidence-Based Radiation Oncology, London: Springer Hermanto, U. et al. (2007) Intensity-modulated radiotherapy (IMRT) and conventional three-dimensional conformal radiotherapy for high-grade
gliomas: Does IMRT increase the integral dose to normal brain? International Journal of Radiation Oncology Biology Physics, 67(4): 1135-1144 Kuo, L. et al. (2008) Setup accuracy of a thermoplastic mask system using two-dimensional (2D) on-board imager (OBI) for fractionated stereotactic
radiotherapy (FSRT). Medical Physics, 35(6): 2825 Louis, D.N. et al. (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathologica, 114: 97-109 Manoj, L. et al. (2011) Review of brain and brain cancer treatment. International Journal of Pharma and Bio Sciences, 2(1): 468-477 Mason, W.P. et al. (2007) Canadian recommendations for the treatment of glioblastoma multiforme. Current Oncology, 14(3): 110-117 Mirimanoff, R.O. et al. (2006) Radiotherapy and temozolomide for newly diagnosed glioblastoma: recursive partitioning analysis of the EORTC
26981/22981-NCIC CE3 phase III randomised trial. Journal of Clinical Oncology, 24: 2563-2569 Mundt, A.J. & Roeske, J. (2011) Chapter 15: Central nervous system tumors: Overview. Image-Guided Radiation Therapy: A Clinical Perspective,
Connecticut: People's Medical Publishing House – USA Preusser, M. et al. (2011) Current concepts and management of glioblastoma. Annals of Neurology, 70: 9-21 Rinne, M.L., Lee, E.Q. & Wen, P.Y. (2012) Central nervous system complications of cancer therapy. The Journal of Supportive Oncology, 10(4): 133-141 Schiff, D. & Wen, P. (2006) Central nervous system toxicity from cancer therapies. Hematology Oncology Clinics of North America, 20: 1377-1398 Stupp, R. et al. (2005) Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. The New England Journal of Medicine, 352: 987-
996 Stupp, R. et al. (2009) Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a
randomised phase III study: 5-year analysis of the EORTC-NCIC trial. The Lancet Oncology, 10: 459-466 Wagner, D. et al. (2009) Radiotherapy of malignant gliomas: Comparison of volumetric single arc technique (Rapidarc), dynamic intensity-modulated
technique and 3D conformal technique. Radiotherapy and Oncology, 93:593-596