Mills-Peninsula Health Services Cancer Symposium - Al Taira, M.D. Dorothy E. Schneider Cancer Center Western Radiation Oncology

1. Al Taira, M.D.
Dorothy E. Schneider Cancer Center
Western Radiation Oncology
Treatment of brain malignancies and other
brain lesions: Emergence of stereotactic
radiosurgery

2. Starting point: Surgical resection
Therapeutic and diagnostic

3. Surgical considerations
 Urgency
 Ambiguity of diagnosis
 Invasive
 Recovery time / perioperative morbidity
 Caution near eloquent and other critical
brain structures
 Extent of surgery
 Patient performance status

4. The innovator
A neurosurgeon from Sweden, Dr.
Lars Leskel, worked for years to
develop a non-invasive means for
“surgically” treating brain tumors.

5. Established fundamental premise of
radiosurgery
High dose to target with
low dose to surrounding
normal tissue.

6. Gamma Knife limitations
• Limited to single fraction treatments
• Brain tumors only
• Long treatment times and some discomfort

7. Next step: CyberKnife
Dr. John
Adler, another
neurosurgeon, pio
neered the next
breakthrough in
stereotactic
radiosurgery.

8. CyberKnife
Advantages (vs Gamma Knife)
No head frame required
Can treat lesions in brain AND rest of body
Limitations
Long treatment times
Limited to only radiosurgery treatments

9. The newest generation
Mills has just installed a state-of-the-
art TrueBeam Varian linear
accelerator developed to optimize
stereotactic radiosurgery
-frameless
-brain and body SRS
-dramatically reduced treatment times
-optimized to deliver highest quality
radiosurgery and IMRT plans

10. Brain metastases
 Approximately 150,000 - 200,000 new cases per year.
 ~10% of cancer patients will develop symptomatic brain metastases
 Primary lung cancers are most common source of brain metastases.
Increasing incidence of women with breast cancer developing brain
metastases due to improvement in systemic therapy.
 With improved identification and treatment of brain metastases, most patients
improve after treatment and do not die from these metastatic lesions.

11. Historic standard: Whole brain
radiotherapy
Treat entire brain parenchyma.
Target known lesions and
potential micrometastases.
Improved survival versus
observation/steroids-alone

12. Whole brain radiotherapy drawbacks
 Fatigue
 Hair loss
 Risk of decreased cognitive functioning
 Risk of decreased overall HRQoL
 2-3 weeks of daily treatments

13. Can we treat initially with SRS
instead?
Aoyama (JAMA 2006) SRS +/- WBRT
No difference in overall survival or initial MMSE.
Chang (Lancet Oncology 2009) SRS +/- WBRT
Inferior neurocognitive outcome and lower OS with WBRT.
Soffietti (JCO 2013) SRS (or surgery) +/- WBRT
Inferior HRQoL with WBRT. No difference in OS.

14. WBRT versus SRS dose distribution
Whole brain radiotherapy Stereotactic radiosurgery
2-3 weeks / daily treatments single short treatment

15. Shifting paradigm
53 year old woman with history breast cancer who completed breast
conservation and adjuvant treatment 2.5 years ago. Now with 3 small
brain metastases.
Traditional paradigm
Original Brain
diagnosis disease-free metastases
interval
WBRT
Emerging paradigm
Original Brain If new brain If more brain
metastasis metastases
diagnosis disease-free metastases disease-free disease-free
interval interval interval
SRS SRS SRS or WBRT

16. Criteria for WBRT versus SRS
• Disease free interval
• Number of new metastases
• Extra-cranial disease control
• Patient performance status

17. Multidisciplinary decision-making:
Brain metastases management
Medical oncologist
SRS
Neurosurgeon Customized
patient plan WBRT
Radiation oncologist Surgery
Patient
Supportive
care

18. Mills intracranial radiosugery
program
• Program started upon delivery of TrueBeam
• Builds on many years of WRO radiosurgery experience
at other cancer centers with wide range of available
technologies
• Close collaboration among medical oncologists,
neurosurgeons, radiation oncologists and radiologists
• Strong physics capabilities and support

19. Radiosurgery capabilities
 Brain metastases
 Schwannomas
 Menigniomas
 Pituitary adenomas
 Vascular disorders
 Functional disorders
 Other