1. FACET - European Journal of Cancer Care March 2006 slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery Gordon, K. 1 Slide One *Click on View; Notes Page for explanatory notes What is stereotactic radiosurgery? Stereotactic radiosurgery is a non- surgical technique used to selectively destroy abnormalities within the brain. Using a machine called the Gamma Knife, 201 sources of Cobalt-60 are focused to a small point (isocentre) ranging from 4-18mm in diameter. This tiny area provides a very high dose of radiation which is used to irradiate a focal point within the brain with sub-millimetre accuracy.

2. FACET - European Journal of Cancer Care March 2006 slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Slide Two *Click on View; Notes Page for explanatory notes History

3. FACET - European Journal of Cancer Care March 2006 slides available at: www.blackwellpublishing.com/journals/ecc Slide Three *Click on View; Notes Page for explanatory notes Stereotactic radiosurgery (continued) Clinical applications Tumours Benign Malignant Functional disorders Vascular disorders

4. FACET - European Journal of Cancer Care March 2006 slides available at: www.blackwellpublishing.com/journals/ecc Slide Four *Click on View; Notes Page for explanatory notes Stereotactic radiosurgery (continued) The procedure Stereotactic radiosurgery is a four stage procedure: 1.Stereotactic frame fixation 2.Imaging procedures 3.3D dose planning 4.Gamma Knife treatment.

5. FACET - European Journal of Cancer Care March 2006 slides available at: www.blackwellpublishing.com/journals/ecc Slide Five *Click on View; Notes Page for explanatory notes Stereotactic radiosurgery (continued) Frame fixation To immobilise the patient, a frame is fixed to the outer layer of the skull under local anaesthetic using four pins.

6. FACET - European Journal of Cancer Care March 2006 Slide Six *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Imaging procedure All patients will undergo some form of radiographic imaging study with the frame in place in order to localise the area to be treated. This will either be: MRI CT Angiography

7. FACET - European Journal of Cancer Care March 2006 Slide Seven *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) 3D dose planning 3D dose planning from the radiographic images.

8. FACET - European Journal of Cancer Care March 2006 Slide Eight *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Gamma Knife treatment

9. FACET - European Journal of Cancer Care March 2006 Slide Nine *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Side effects Headaches (most common side effect) Occasional hair loss Other symptoms due to raised intracranial pressure and oedema (nausea, vomiting) Effects of radiation damage to normal tissues: Cranial nerves Optic apparatus Brain stem Necrosis

10. FACET - European Journal of Cancer Care March 2006 Slide Ten *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Acoustic neuroma TV at treatment: 6.8cc TV at 7 months follow-up: 7.4cc TV at 1yr follow-up: 3.2cc N.B. cc = cubic centimetres

11. FACET - European Journal of Cancer Care March 2006 Slide Eleven *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Single melanoma metastasis TV at treatment: 17.0ccTV at 5 month follow- up: 1.0cc TV at 1year follow- up: 1.0cc TV at 1yr 3month follow-up: 0.756cc

12. FACET - European Journal of Cancer Care March 2006 Slide Twelve *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Multiple metastases: breast 3D view at treatment 10 metastases. Total volume = 13.9 cm 3 3D View at 6 month follow-up. Only 3 metastases now visible on triple dose contrast enhanced MRI Total volume = 0.6 cm 3

13. FACET - European Journal of Cancer Care March 2006 Slide Thirteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Summary (1) Excellent treatment approach for a number of brain abnormalities Non invasive Single treatment requiring a short hospital stay

14. FACET - European Journal of Cancer Care March 2006 Slide Fourteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) Summary (2) Very few (if any) side effects Limitations – due to the nature of the radiation it is more effective when delivered to small areas. Therefore, there is limited use in large tumours and patients are referred for more conventional treatments.

15. FACET - European Journal of Cancer Care March 2006 Slide Fifteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) The future More research to realise the potential in areas such as Parkinson's disease and epilepsy. Publish results of such trials, raising awareness within the medical community therefore opening the treatment up to more patients. Open more centres around the world to make the treatment more available.

16. FACET - European Journal of Cancer Care March 2006 Slide Sixteen *Click on View; Notes Page for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Stereotactic radiosurgery (continued) References and further reading http://www.gammaknife.co.uk http://www.elekta.com http://www.irsa.org/radiosurgery.html Gordon K, Eddy D. (2006) The efficacy of Stereotactic Radiosurgery in the management of Vestibular Schwannomas - a retrospective analysis. Journal of Radiotherapy in Practice. 5 (1): 1-12. Hickey, K. (2004) Role of stereotactic radiosurgery in the management of single or multiple cerebral metastases. Journal of Radiotherapy in Practice. 3 (4): 197-203. Hickey, K. (2004) Conventional and contemporary management approaches for the treatment of vestibular schwannomas: Microsurgery versus radiosurgery, a literature review. Journal of Radiotherapy in Practice. 4 (1): 39-45.