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Reirradiation of multiple brain metastases with helical tomotherapy

A multifocal simultaneous integrated boost for eight or more lesions

Rebestrahlung multipler Hirnmetastasen mittels helikaler Tomotherapie. Multifokaler simultaner integrierter Boost für acht oder mehr Läsionen

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Background and Purpose:

Recurrent brain metastases or new brain lesions after whole-brain radiotherapy represent a therapeutic challenge. While several treatment methods for single or few lesions have been described, options for multiple lesions are limited. This case report is intended to show an approach of whole-brain reirradiation with a simultaneous multifocal integrated boost using helical tomotherapy. Technique, feasibility, and acute side effects are presented.

Patients and Methods:

Two patients with multiple relapsed brain metastases (eight and eleven lesions) were reirradiated after previous whole-brain radiotherapy (total dose of 40 Gy 18 months before). Whole-brain reirradiation was performed using helical tomotherapy with a total dose of 15 Gy (single dose 1.5 Gy) and a multifocal simultaneous integrated boost with a total dose of 30 Gy (single dose 3 Gy) to the brain lesions. The boost planning target volume was delineated around the lesions visible on MRI plus a 2-mm margin. Follow-up of these patients was 6 and 12 months.

Results:

Radiation plans with excellent conformity and homogeneity were obtained. High dose exposure to normal brain tissue was kept minimal. Mean radiation time was 13 min. The only acute side effect observed was a mild headache over 2 days at the end of treatment. So far, no further side effects and no signs of recurrence have been observed.

Conclusion:

Helical tomotherapy offers new treatment options for the reirradiation of multiple brain metastases. The number of cases treated with the described protocol is very limited but it is considered a promising option for patients that have responded well to the initial radiotherapy and are in a good performance status.

Hintergrund und Ziel:

Rezidive von Hirnmetastasen oder neue Herde nach vorangegangener Ganzhirnbestrahlung stellen eine therapeutische Herausforderung dar. Während mehrere Techniken zur Behandlung singulärer oder weniger Läsionen beschrieben wurden, sind die Optionen bei multiplen Metastasen limitiert. Dieser Fallbericht beschreibt einen Ansatz der Ganzhirnrebestrahlung mit simultanem multifokalem integriertem Boost mittels helikaler Tomotherapie. Technik, Machbarkeit und akute Nebenwirkungen werden berichtet.

Patienten und Methodik:

Zwei Patienten mit multiplen Rezidiven von Hirnmetastasen (acht bzw. elf Herde) wurden nach vorangegangener Ganzhirnradiotherapie rebestrahlt (40 Gy 18 Monate zuvor). Mittels helikaler Tomotherapie wurden das Neurokranium mit einer Dosis von 15 Gy (Einzeldosis 1,5 Gy) und die Metastasen selbst mit einem multifokalen simultanen integrierten Boost mit einer Dosis von 30 Gy (Einzeldosis 3 Gy) rebestrahlt. Das Planungszielvolumen des Boosts wurde mit einem 2-mm-Sicherheitssaum um die Kontrastmittelaufnahme im MRT definiert. Der Nachbeobachtungszeitraum dieser Patienten betrug 6 bzw. 12 Monate.

Ergebnisse:

Es konnten Bestrahlungspläne mit hervorragender Konformität und Homogenität erreicht werden. Die Hochdosisbelastung des Hirnparenchyms konnte gering gehalten werden. Die mittlere Bestrahlungszeit betrug 13 min. Einzige Akutnebenwirkung war ein geringer Kopfschmerz zum Ende der Behandlung. Es wurden keine weiteren Toxizitäten oder Zeichen eines Rezidivs beobachtet.

Schlussfolgerung:

Die helikale Tomotherapie eröffnet neue Optionen in der Rebestrahlung multipler Hirnmetastasen. Die Anzahl der so behandelten Patienten ist sehr limitiert, dennoch erscheint diese Behandlungsmöglichkeit sehr vielversprechend für Patienten, die auf die initiale Therapie gut angesprochen haben.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany

    Klaus K. Herfarth

  2. Department of Radiation Oncology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany

    Florian Sterzing MD

Authors
  1. Florian Sterzing MD
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  2. Thomas Welzel
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  3. Gabriele Sroka-Perez
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  4. Kai Schubert
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  5. Jürgen Debus
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  6. Klaus K. Herfarth
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Correspondence to Florian Sterzing MD.

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Sterzing, F., Welzel, T., Sroka-Perez, G. et al. Reirradiation of multiple brain metastases with helical tomotherapy. Strahlenther Onkol 185, 89–93 (2009). https://doi.org/10.1007/s00066-009-1971-2

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  • DOI: https://doi.org/10.1007/s00066-009-1971-2

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