Amelia glioblastoma

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  • 1. The Role of External Beam Radiation Therapy

2. Brain, Spinal cord, Meninges Primary or Metastatic Metastatic cancers of the CNS are morecommon Types of CNS tumours: Gliomas Spinal cord tumours Intracranial germ celltumours Figure 1. The brain and spinal cord of the CNS 3. Figure 2. Frequency of all primary CNS gliomas. Adamson, C., et al. (2009) Glioblastoma multiforme: Areview of where we have been and where we are going. Expert Opinion on Investigational Drugs, 18(8): 1061-1083 4. Extensive microvascular infiltration Rapid proliferation High rates of recurrence Presenting features: Seizures Headaches Focal neurologic deficits Etiology unknown 5. 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 6. Table 1. WHO classification system for CNS tumours 7. Figure 3. Treatment management approach for glioblastoma 8. External beam vs. Stereotactic, Brachytherapy, Hyperfractionation, Radioenhancers, BCNT, Accelerated, Dose escalation 3DCRT vs. IMRT vs. RapidarcTable 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 9. Supine Thermoplasticimmobilization mask CT with intravenouscontrastFigure 4. Contrast enhanced CT of brain. Arrow indicatesGBM multiforme. Drislane, F. et al. (2006) Chapter 19: BrainTumors. Blueprints Neurology, Philadelphia: Lippincott Williams &Wilkins 10. 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 11. Figure 5. (A) Target delineation of a GBM. GTV outlined in blue. CTV with an additional 2cm margin to cover microscopicdisease 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 12. 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 13. Patients with GBM have a relatively poor prognosis andmuch research is needed in the way of improvedtreatment 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 brainRT and the advantages/disadvantages of different EBRTtechniques which may assist in planning If performing IMRT or Rapidarc, additional QA measure must betaken Be aware of associated side effects and flag to appropriatemember of MDT if thought necessary 14. 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. Radiotherapyand 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 andBartlett 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 IMRTincrease 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-NCICCE3 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: PeoplesMedical 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 randomisedphase 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 and3D conformal technique. Radiotherapy and Oncology, 93:593-596