Purpose As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy investigating normal tissue complication probability (NTCP) after hypofractionated radiation therapy, data from published reports (PubMed indexed 1995-2018) were pooled to identify dosimetric and clinical predictors of radiation-induced brain toxicity after single-fraction stereotactic radiosurgery (SRS) or fractionated stereotactic radiosurgery (fSRS). Methods and Materials Eligible studies provided NTCPs for the endpoints of radionecrosis, edema, or symptoms after cranial SRS/fSRS and quantitative dose-volume metrics. Studies of patients with only glioma, meningioma, vestibular schwannoma, or brainstem targets were excluded. The data summary and analyses focused on arteriovenous malformations (AVM) and brain metastases. Results Data from 51 reports are summarized. There was wide variability in reported rates of radionecrosis. Available data for SRS/fSRS for brain metastases were more amenable to NTCP modeling than AVM data. In the setting of brain metastases, SRS/fSRS-associated radionecrosis can be difficult to differentiate from tumor progression. For single-fraction SRS to brain metastases, tissue volumes (including target volumes) receiving 12 Gy (V12) of 5 cm3, 10 cm3, or >15 cm3 were associated with risks of symptomatic radionecrosis of approximately 10%, 15%, and 20%, respectively. SRS for AVM was associated with modestly lower rates of symptomatic radionecrosis for equivalent V12. For brain metastases, brain plus target volume V20 (3-fractions) or V24 (5-fractions) Conclusions The risk of radionecrosis after SRS and fSRS can be modeled as a function of dose and volume treated. The use of fSRS appears to reduce risks of radionecrosis for larger treatment volumes relative to SRS. More standardized dosimetric and toxicity reporting is needed to facilitate future pooled analyses that can refine predictive models of brain toxicity risks.

Single- and Multifraction Stereotactic Radiosurgery Dose/Volume Tolerances of the Brain.

Purpose Dosimetric and clinical predictors of radiation-induced optic nerve/chiasm neuropathy (RION) after single-fraction stereotactic radiosurgery (SRS) or hypofractionated (2-5 fractions) radiosurgery (fSRS) were analyzed from pooled data that were extracted from published reports (PubMed indexed from 1990 to June 2015). This study was undertaken as part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, investigating normal tissue complication probability (NTCP) after hypofractionated radiation. Methods and Materials Eligible studies described dose delivered to optic nerve/chiasm and provided crude or actuarial toxicity risks, with visual endpoints (ie, loss of visual acuity, alterations in visual fields, and/or blindness/complete vision loss). Studies of patients with optic nerve sheath tumors, optic nerve gliomas, or ocular/uveal melanoma were excluded to obviate direct tumor effects on visual outcomes, as were studies not specifying causes of vision loss (ie, tumor progression vs RION). Results Thirty-four studies (1578 patients) were analyzed. Histologies included pituitary adenoma, cavernous sinus meningioma, craniopharyngioma, and malignant skull base tumors. Prior resection (76% of patients) did not correlate with RION risk (P = .66). Prior irradiation (6% of patients) was associated with a crude 10-fold increased RION risk versus no prior radiation therapy. In patients with no prior radiation therapy receiving SRS/fSRS in 1-5 fractions, optic apparatus maximum point doses resulting in Conclusions Optic apparatus NTCP and tolerance doses after single- and multi-fraction stereotactic radiosurgery are presented. Additional standardized dosimetric and toxicity reporting is needed to facilitate future pooled analyses and better define RION NTCP after SRS/fSRS.

Single- and Multi-Fraction Stereotactic Radiosurgery Dose Tolerances of the Optic Pathways

The optimal management of large vestibular schwannomas continues to be debated. We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of this problem from a European perspective. A systematic review of MEDLINE database, in compliance with the PRISMA guidelines, was performed. A subgroup analysis screening all surgical series published within the last 20 years (January 2000 to March 2020) was performed. Weighted summary rates for tumor resection, oncological control, and facial nerve preservation were determined using meta-analysis models. This data along with contemporary practice patterns were discussed within the task force to generate consensual recommendations regarding preoperative evaluations, optimal surgical strategy, and follow-up management. Tumor classification grades should be systematically used in the perioperative management of patients, with large vestibular schwannomas (VS) defined as > 30 mm in the largest extrameatal diameter. Grading scales for pre- and postoperative hearing (AAO-HNS or GR) and facial nerve function (HB) are to be used for reporting functional outcome. There is a lack of consensus to support the superiority of any surgical strategy with respect to extent of resection and use of adjuvant radiosurgery. Intraoperative neuromonitoring needs to be routinely used to preserve neural function. Recommendations for postoperative clinico-radiological evaluations have been elucidated based on the surgical strategy employed. The main goal of management of large vestibular schwannomas should focus on maintaining/improving quality of life (QoL), making every attempt at facial/cochlear nerve functional preservation while ensuring optimal oncological control, thereby allowing to meet patient expectations. Despite the fact that this analysis yielded only a few Class B evidences and mostly expert opinions, it will guide practitioners to manage these patients and form the basis for future clinical trials.

/pdf/surgical-management-for-large-vestibular-schwannomas-a-4obout45ut.pdf

Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section.

ESTRO ACROP guideline for target volume delineation of skull base tumors

Managing Essential Tremor

Objectives The aim of this systematic review was to develop International Stereotactic Radiosurgery Society (ISRS) consensus guideline statements for vestibular schwannoma. Methods A systematic review of the literature was performed up to April 2015. Results A total of 55 full-text articles were included in the analysis. All studies were retrospective, except for 2 prospective quality of life studies. Five-year tumour control rates with Gamma Knife radiosurgery (RS), single fraction linac RS, or fractionated (either hypofractionated or conventional fractionation) stereotactic radiation therapy (FSRT) were similar at 81-100%. The single fraction RS series (linac or Gamma Knife) with tumour marginal doses between 12 and 14 Gy revealed 5-year tumour control rates of 90-99%, hearing preservation rates of 41-79%, facial nerve preservation rates of 95-100% and trigeminal preservation rates of 79-99%.There were 6 non-randomized studies comparing single fraction RS versus FSRT. There was no statistically significant difference in tumour control; HR=1.66 (95% CI 0.81, 3.42), p =0.17, facial nerve function; HR = 0.67 (95% CI 0.30, 1.49), p =0.33, trigeminal nerve function; HR = 0.80 (95% CI 0.41, 1.56), p =0.51, and hearing preservation; HR = 1.10 (95% CI 0.72, 1.68), p =0.65 comparing single fraction RS with FSRT.Nine quality of life reports yielded conflicting results as to which modality (surgery, observation, or radiation) was associated with better quality of life outcomes. Conclusions There are no randomized trials to help guide management of patients with vestibular schwannoma. Within the limitations of the retrospective series, a number of consensus statements were made.

Stereotactic radiosurgery for vestibular schwannoma: International Stereotactic Radiosurgery Society (ISRS) Practice Guideline.

Radiosurgery Nomenclature: A Confusion of

Since the time of its inception within neurosurgery, the practice of radiosurgery has grown and evolved with the introduction of new technologies and the involvement of other disciplines. Currently, radiosurgery practices involve neurosurgery, radiation oncology, medical physics and, in many centers, neuroradiology. Various commercially available radiosurgical devices are used, including the conventional linear accelerator, CyberKnife, Gamma Knife, and even particle therapy units. The historical roots of each radiosurgery practice affect the terminology and procedures applied for treatment planning and delivery, resulting in wide variability in image acquisition, planning, and verification practices across the community. This organic development has led to a “confusion of tongues,” challenging our ability to interpret the published scientific literature in a meaningful way and hindering the radiosurgery community’s ability to collaborate effectively to advance the science and practice of radiosurgery. The broader radiation therapy literature contains a growing body of evidence that the quality of radiation delivery has a significant impact on clinical outcomes. This was highlighted in a secondary report of a large multicenter phase 3 trial of head and neck cancer, which showed

Radiosurgery Nomenclature: A Confusion of Tongues

OBJECTIVEThe aim of this systematic review is to offer an objective summary of the published literature relating to stereotactic radiosurgery (SRS) for tremor and consensus guideline recommendations.METHODSThis systematic review was performed up to December 2016. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The following key words were used: "radiosurgery" and "tremor" or "Parkinson's disease" or "multiple sclerosis" or "essential tremor" or "thalamotomy" or "pallidotomy." The search strategy was not limited by study design but only included key words in the English language, so at least the abstract had to be in English.RESULTSA total of 34 full-text articles were included in the analysis. Three studies were prospective studies, 1 was a retrospective comparative study, and the remaining 30 were retrospective studies. The one retrospective comparative study evaluating deep brain stimulation (DBS), radiofrequency thermocoagulation (RFT), and SRS reported similar tremor control rates, more permanent complications after DBS and RFT, more recurrence after RFT, and a longer latency period to clinical response with SRS. Similar tremor reduction rates in most of the reports were observed with SRS thalamotomy (mean 88%). Clinical complications were rare and usually not permanent (range 0%-100%, mean 17%, median 2%). Follow-up in general was too short to confirm long-term results.CONCLUSIONSSRS to the unilateral thalamic ventral intermediate nucleus, with a dose of 130-150 Gy, is a well-tolerated and effective treatment for reducing medically refractory tremor, and one that is recommended by the International Stereotactic Radiosurgery Society.

/pdf/stereotactic-radiosurgery-for-tremor-systematic-review-sxb391ucsb.pdf

Stereotactic radiosurgery for tremor: systematic review.

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Stereotactic radiosurgery for vestibular schwannoma: International Stereotactic Radiosurgery Society (ISRS) Practice Guideline.

Radiosurgery Nomenclature: A Confusion of

Radiosurgery Nomenclature: A Confusion of Tongues

Stereotactic radiosurgery for tremor: systematic review.