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Radiation treatment parameters for re-irradiation of malignant glioma

Behandlungsparameter für Re-Bestrahlung beim malignen Gliom

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Abstract

Background and purpose

Most patients with malignant glioma ultimately fail locally or loco-regionally after the first treatment, with re-irradiation being a reasonable treatment option. However, only limited data are presently available allowing for a precise selection of patients suitable for re-treatment with regard to safety and efficacy.

Material and methods

Using the department database, 39 patients with a second course of radiation were identified. Doses to gross tumor volume (GTV), planning target volume (PTV), and relevant organs at risk (OARs; brainstem, optic chiasm, optic nerves, brain) were retrospectively analyzed and correlated to outcome parameters. Relevant treatment parameters including Dmax, Dmin, Dmean, and volume (ml) were obtained. Equivalent uniform dose (EUD) values were calculated for the tumor and OARs. To address the issue of radiation necrosis/leukoencephalopathy posttherapeutic MRI images were routinely examined every 3 months.

Results

Median follow-up was 147 days. The time interval between first and second irradiation was regularly greater than 6 months. Median EUDs to the OARs were 11.9 Gy (range 0.7–27.4 Gy) to the optic chiasm, 17.6 Gy (range 0.7–43.0 Gy) to the brainstem, 4.9/2.1 Gy (range 0.3–24.5 Gy) to the right/left optic nerve, and 29.4 Gy (range 25.2–32.5 Gy) to the brain. No correlation between treated volume and survival was observed. Cold spots and dose did not correlate with survival. Re-irradiated volumes were treated with on average lower doses if they were larger and vice versa.

Conclusion

In general, re-irradiation is a safe and feasible re-treatment option. No relevant toxicity was observed after re-irradiation in our patient cohort during follow-up. In this regard, this analysis provides baseline data for the selection of putative patients. EUD values are derived and may serve as reference for further studies, including intensity-modulated radiotherapy (IMRT) protocols.

Zusammenfassung

Hintergrund und Ziel

Die meisten Patienten mit einem malignen Gliom erleiden ein lokales oder lokoregionäres Rezidiv nach Erstbehandlung. Dabei stellt die Möglichkeit einer Re-Bestrahlung eine vernünftige Therapieoption dar. Allerdings liegen gegenwärtig noch keine validen Daten vor, die eine präzise Patientenselektion hinsichtlich der Behandlungseffektivität und -sicherheit erlauben.

Material und Methoden

Mit Hilfe der klinikeigenen Datenbank wurden 39 Patienten identifiziert, die eine erneute Strahlentherapie im Rezidiv erhalten hatten. Die Strahlendosen in „gross tumor volume“ (GTV), „planning target volume“ (PTV) und relevanten Risikoorganen (Hirnstamm, Chiasma opticum, Sehnerven, Gehirn) wurden retrospektiv ausgewertet und mit den Behandlungsergebnissen korreliert. Relevante Behandlungsparameter wie Dosismaxima (Dmax), -minima (Dmin), -mittelwerte (Dmean) und Volumina (ml) wurden erhoben. „Equivalent uniform dose“ (EUD)-Werte wurden für Tumor und Risikoorgane berechnet. Um eine potentielle Radionekrose adäquat zu erfassen, wurden posttherapeutisch regelmäßig alle 3 Monate MRT-Bildgebungen durchgeführt.

Ergebnisse

Das mediane Follow-Up betrug 147 Tage. Das Zeitintervall zwischen 1. und 2.  Bestrahlungsserie lag regelhaft über 6 Monaten. Die medianen EUD-Werte an den Risikoorganen betrugen am Chiasma opticum 11,9 Gy (range 0,7–27,4 Gy), 17,6 Gy (range 0,7–43,0 Gy) am Hirnstamm, am rechten bzw. linken Sehnerv 4,9 bzw. 2,1 Gy (range 0,3–24,5 Gy) und am Gehirn 29,4 Gy (range 25,2–32,5 Gy). Eine Korrelation zwischen behandeltem Volumen und Überleben wurde nicht beobachtet. Die Dosis bzw. fokale Unterdosierungen korrelierten ebenfalls nicht mit dem Überleben. Größere re-bestrahlte Volumina wurden im Durchschnitt mit niedrigeren Gesamtdosen behandelt und umgekehrt.

Schlussfolgerung

Grundsätzlich ist die Re-Bestrahlung eine sichere und durchführbare Option im Rezidiv. In der Nachbeobachtung nach erneuter Strahlentherapieserie wurde in unserem Kollektiv keine relevante Toxizität beobachtet. Dahingehend liefert die vorliegende Analyse grundlegende Daten zur Selektion potentieller Patienten. EUD-Werte wurden generiert und könnten künftig als Referenz für weitere Studien einschließlich IMRT-Behandlungsprotokollen dienen.

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Abbreviations

3D-CRT:

3D conformal radiotherapy

CNS:

central nervous system

CT:

computed tomography

Dmax, min, mean :

maximum, minimum, mean dose

DVH:

dose–volume histogram

EUD:

equivalent uniform dose

FET:

18F-fluoroethyltyrosine

FSRT:

fractionated stereotactic radiotherapy

GTV:

gross tumor volume

IMRT:

intensity-modulated radiotherapy

MG:

malignant glioma

MGMT:

O6-methylguanine-DNA methyltransferase

MRI:

magnetic resonance imaging

NTCP:

normal tissue complication probability

NTD:

normalized total dose

OAR:

organs at risk

PET:

positron emission tomography

PTV:

planning target volume

RT:

radiotherapy

SRS:

stereotactic radiosurgery

TMZ:

temozolomide

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Authors’ contributions

UG, CB, and MN planned, coordinated, and performed the study. PL provided information on physical treatment planning. MS provided assistance on EUD theory as well as EUD calculation. MN, MS, CB, SBS, and UG prepared the manuscript. All authors read and approved the final manuscript.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Radiation Oncology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany

    M. Niyazi, M. Söhn, S.B. Schwarz, P. Lang, C. Belka & U. Ganswindt

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  1. M. Niyazi
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  2. M. Söhn
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  3. S.B. Schwarz
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  4. P. Lang
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  5. C. Belka
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  6. U. Ganswindt
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Correspondence to M. Niyazi.

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Niyazi, M., Söhn, M., Schwarz, S. et al. Radiation treatment parameters for re-irradiation of malignant glioma. Strahlenther Onkol 188, 328–333 (2012). https://doi.org/10.1007/s00066-011-0055-2

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