1. Neuro-oncology Brain metastases Glioma Grade 4 > Grade 3 > Grade 2 Pituitary tumours Ependymomas Lymphoma P.N.E.T. (Primitive neuro ectodermal tumour) Pineal Tumours inc germ cell tumours Atypical Meningiomas Primary spinal tumours

2. Pituitary Irradiation Questions What are the indications for radiotherapy ? What does conventional radiotherapy involve? Radiosurgery ? What is stereotactic linear accelerator based radiotherapy ?

3. Indications for Pituitary Irradiation Suprasellar extension Cavernous sinus involvement Recurrent Disease Uncontrolled endocrinopathy Medically unfit

4. Suprasellar Extension Pre op Post op

5. Cavernous sinus involvement

6. Recurrent Disease

7. Uncontrolled Endocrine Effects

8. Results

9. Results 90% control of Pituitary tumour at 10 years following surgery and radiotherapy

10. Visible tumour Gross Tumour Volume (GTV) GTV plus Normal tissue containing microscopic disease Clinical Target Volume (CTV) CTV plus Further tissue to allow for organ movement, set up Planning Target Volume (PTV) Radiotherapy Planning

11. Suprasellar Extension Pre op Post op

12. Conventional Radiotherapy Standard immobilisation shell CT planning scan Fractionated treatment (25 usually)

13. Conventional Radiotherapy

15. Intention is to reduce the set up margin by more rigid immobilisation and conforming beams. Field size restricted to smaller fields Main indication when the subclinical invasion is minmal Benign, AVM, or only treating GTV Stereotactic Radiotherapy

16. Stereotactic Radiotherapy Precise positioning in three-dimensional space. In stereotactic surgery, a system of three-dimensional coordinates is used to locate the site to be operated on. In stereotactic radiotherapy, a system of three-dimensional coordinates is used to locate the site to be irradiated by a number of precisely aimed beams of ionizing radiation from diverse directions meeting at a specific point.

17. Stereotactic Radiotherapy

18. Leksell Unit Stereotactic Radiosurgery

19. Leksell Unit Stereotactic Radiosurgery

20. Single fraction Ablative dose Use for lesions where there is no significant subclinical spread. Small fields 4cm or less Immobilisation imperative Examples AVM Acoustic neuromas Meningiomas Metastases Stereotactic Radiosurgery

21. Linac based system Stereotactic Radiosurgery Stereotactic Radiotherapy

22. Multiple conventional fractions exploits reduced patient movement to reduce morbidity Use for lesions where there is minimal subclinical spread or as a boost to GTV only Immobilisation device must allow for repositioning daily Examples Pituitary tumours Meningiomas Gliomas (needs further studies) Stereotactic Linear accelerator based Radiotherapy

23. Conventional Radiotherapy Plan unavoidable dose to normal structures outside target volume Intensity Modulated Radiotherapy (I.M.R.T.)

24. Multiple beams, non uniform dose across the beam Intensity Modulated Radiotherapy (I.M.R.T.)

25. Radiotherapy Side Effects During Tired, Hair loss, tumour swell 2 months Somnolence, Recurrent symptoms: recurrence, necrosis or tumour swell 6 months Late radiation necrosis 2 years Intellectual deterioration

27. Late Effects Tumourigenesis Some studies find patients who have had standard pituitary radiation therapy are at a 9.4- to 16-fold increased risk for malignant brain tumours (such as astrocytomas or gliomas) in comparison with the risk in the general population.

28. Pituitary Irradiation Summary Indications Conventional vs more technical radiotherapy Side effects usually rare and manageable