Transcript
First, I'd like to thank Brain Lab for inviting me here to be with you. My topic will be on "The Benefits of Data Enrichment Solutions for Gamma Knife Radiosurgery Planning." All of you know that Gamma Knife radiosurgery was installed first in 1968. It means that today we are celebrating its 50 years of age, and about 330 centers all over the world doing Gamma Knife radiosurgery, and more than 1.2 million patients have been treated with Gamma Knife radiosurgery.
The first software for GammaPlan was KULA. And after that, in the following years, GammaPlan's came to the stage. In the beginning of my work, I worked with GammaPlan 5. Today, we use GammaPlan 10 for Perfexion and GammaPlan 11 for Icon. Of course, there have been so many, many improvements in the GammaPlan's in these years.
So today, I want to discuss some issues. The first one is distortion of MR images. We know that the old MR images has distortion. Low or high, but all has distortion. The degree of distortion is different in all MR scans. The brands are different also. The distortions are larger in the peripheral region of the image. And large bore scanners, it is good for the patients, but they induce larger distortions, and distortion levels are not equal in all MR sequences. Distortion level is lowest in the 1.5 Tesla system, and all MRI images, even they have distortion correction feature. Even with that, those images have distortions.
So, to have a distortion in MR image is very important for us, because we are trying to be very precise while giving the radiation, high amount of radiation to that area. Today, for many years, we can co-register MR to CT, because we know that CT has less distortion, less than MR. And we can do co-registration with rigid fashion or elastic co-registration. And elastic co-registration is better than rigid co-registration.
Here you see a [inaudible 00:02:41] patient. And the red dots you'll see there represents the high distortion area. And here are the images, and you see the high distortion areas is periphery, it is at the periphery of the brain. But if the MR image, if the maintenance of your MR image in your hospital doesn't get regularly, your MRI images can be very distorted. So, I want to show you a video right now, it will automatically run. You see here the T2 and CT of the patient. You see here the discrepancy of the bony borders in the temporal region. So, when we order the computer elements to do the distortion correction, we will see the result. You see here, the red dots which has the more distortion, and the window going to that area. And you see this is better than before. So, of course the level, of course the measurement is so low. But we have to correct it, because we want to be very precise.
So, for example, in this patient, I hope you can see it from there. We have two sets of images here. In the first set, in the upper set, you see the original MR of the patient with the drawing of the tumor. It's a hemangioblastoma patient. And in the bottom line, you'll see the distortion corrected MR and the original drawing on that MR. You see some part of the tumor on the back side on the posterior side is missing. And if I irradiated this patients original MR I would miss some part of the tumor here. This side, you see?
Another patient with residual vestibular schwannoma after surgery. The upper set shows us the original MR with drawing of the tumor. The lower set shows that the drawing depending on the original set is different than the drawing in the distortion corrected MR. So, if I irradiated the original MR, I would miss some part of the real placement of the tumor.
Another patient, same thing, I could miss the part of the tumor, if I don't do a distortion correction. This is a patient with breast cancer metastases to cerebellum. And the blue line shows me the outlining of the tumor depending on the original MR. And the red line shows us the outline of the tumor depending on the distortion corrected one. From the sagittal image and the coronal image, you can see the difference.
The next topic will be the target definition-contouring anatomical atlas-organ at risk definition. To do target definition Gamma Knife radiosurgery, I mean GammaPlan, takes maybe two, five minutes. Of course, if you have a very complex skull-based meningioma, it may take maybe 10 minutes to draw the tumor correctly. But with an Element's [SP] 3D brush, it takes only one minute. I will show you a video.
And also, organ at risk definition depends on the image that you want to draw organ at risk. You may want to draw one organ, for example, only one optic nerve, or you may want to draw all the important structures in the brain. It takes time. But with Element, you can do it in less than five minutes. And in this video, you will see there as a meningioma here, you see? It's very easy, very straightforward. You can draw the tumor from the axial section. Then you can use coronal or sagittal, which one you want. Then you will see the 3D image of the tumor, and all slices can be reviewed. If you see any problem there, you can correct it. And it's very easy, because it takes time with GammaPlan.
But you must be very careful, because in this patient with a small meningioma in the parasellar area, it was compressing the left optic nerve. You see? I wanted to see the left optic nerve, because I want to spare it from the radiation effect. So, I wanted Element to draw the left optic nerve, but I think you can see here, the blue line here is in the tumor. So, for these kinds of small areas, small tumors with tiny optic nerves, Element may not see the exact position. Of course, to see the optic nerve there is also hard for me. And it is hard for Element too.
This is the treatment plan of this patient. But for the large area, for example, brainstem in a petroclival meningioma patient, it's easy to draw it by Element. And you can export all these structures to your GammaPlan and use it there. For example, this is a picture from GammaPlan. And you can see here the optic nerve is here, which is drawn by Element. And the tumor is here and the brainstem is there.
And this is the treatment plan of the patient. Other issue which we can use for GammaPlan is about radiation necrosis and adverse radiation effect. Of course, it is very important to differentiate between necrosis and the tumor recurrence. We don't want to irradiate the necrotic tissue, necrotic brain, necrotic tumor. Of course, we have many MR sequences, different techniques, to differentiate between tumor recurrence and necrosis.
Yesterday, we listened to a perfect presentation from one of our friends. And we can use contrast clearance system or TRAM for our patient's treatment. Roughly, and to remind you, only I will say that, I don't...I'm not going to go very deep. The blue areas which we see in TRAM is living tumoral tissue, and the red is necrotic tissue. I want to show you two case examples. One of them is a 53-year-old male with lung cancer. He came to stage with this multiple metastases. And in another hospital, they decided to give whole-brain radiotherapy to him. And after six months, six months later, his confirmed MRI image and TRAM contrast clearance showed this image.
So here, this is the pre-radiotherapy image. And today, you see the tumor in the cerebellum is in TRAM image. The part of the tumor is living tumoral cells, but most part of the tumor is necrotic. For other tumor, the second tumor, you see on the temporal lobe, it is mostly necrotic. But the periphery of the tumor here is living, has living tissue. Okay? So we have to target this area. And for the other tumor here, you see, it has some necrotic areas, but it's mostly viable tissue there, viable tumor tissue there. So we irradiated the tumor areas, the blue areas with Gamma Knife. And three months later, we had a second TRAM examination for this patient.
You see, it was three months ago. And now you see, all the tumoral area is red, is necrotic. So, for this temporal tumor, the same, old area is necrotic. And this is same for this one. But we did see another tumor in the cerebellum, which has necrotic part, plus tumoral part, okay, living tumoral tissue. So, we only irradiated that the tumoral part, which is close to tentorial in this patient.
This is the second case. She's 45 years old female with breast cancer. Had whole-brain radiotherapy for multiple metastases now at the hospital. And one year later, she came to us with new metastases. And we get the TRAM examination for this patient too. You see here? The tumor...and the TRAM shows us that it is completely blue. So, it is a living tumor there. So let's see this one. There is a tumor here. And with TRAM, you see, it is completely blue. So, we have to do something for that tumor too.
This is interesting. You see here, two parts, this part, another part here, you see? In TRAM, you see the medial part is necrotic. But the lateral part of the tumor is living. There's a recurrence. So, we have to target that part only. And also she has some other tumors of course, but those tumors demonstrated necrosis in TRAM. So, we don't need to target them in our Gamma Knife treatment. So, we irradiated all these three tumors that we see in TRAM.
And the last thing I would like to share with you, AVM treatment. And of course, other speakers talked here, said the same thing. The nidus definition in AVM is very important. And it differs from author to author. If we all people here see same MR and angiography image in the same...from same patient, we will draw the nidus differently. So, it's very important. So I would recommend for the newbies, don't begin with AVM radiosurgery, begin with metastases radiosurgery, for example. Where to irradiate and where is the nidus is very important in AVM radiosurgery. The traditional way in Gamma Knife radiosurgery, we were applying the frame on the patient's head. Get MR imaging, get stereotactic angiography and do the planning and do the treatment.
Is MR necessary? Yes, it is necessary. We have to do it. But if a patient has incompatible indication for MR, you can get CT. Is stereotactic DSA necessary? For frameless AVM treatment, for many years, we know that these features we can target the AVM with new Smart Brush of Element, you can do it without frame. So, you need T1 contrast or TOF MR image of the patient, and of course, diagnostic angiography of the patient. When you import these to the computer, you will see the branches of the vessels in the brain, and you have to combine them, the DSA and image from the MR. Then for these small ion, for these small AVMs, you can see the target. And you can draw the target from the Element, then send it to the GammaPlan and you can do your treatment there.
Another patient with an occipital, you see here, the images. And this is the treatment plan of the patient. And you see here, I didn't use stereotactic angiography in this patient. As a conclusion, I would say that there are many options to improve radiosurgical treatment for our patients, and to improve the success of the treatment and quality of life. We have to use these technological improvements. Thank you very much.
The first software for GammaPlan was KULA. And after that, in the following years, GammaPlan's came to the stage. In the beginning of my work, I worked with GammaPlan 5. Today, we use GammaPlan 10 for Perfexion and GammaPlan 11 for Icon. Of course, there have been so many, many improvements in the GammaPlan's in these years.
So today, I want to discuss some issues. The first one is distortion of MR images. We know that the old MR images has distortion. Low or high, but all has distortion. The degree of distortion is different in all MR scans. The brands are different also. The distortions are larger in the peripheral region of the image. And large bore scanners, it is good for the patients, but they induce larger distortions, and distortion levels are not equal in all MR sequences. Distortion level is lowest in the 1.5 Tesla system, and all MRI images, even they have distortion correction feature. Even with that, those images have distortions.
So, to have a distortion in MR image is very important for us, because we are trying to be very precise while giving the radiation, high amount of radiation to that area. Today, for many years, we can co-register MR to CT, because we know that CT has less distortion, less than MR. And we can do co-registration with rigid fashion or elastic co-registration. And elastic co-registration is better than rigid co-registration.
Here you see a [inaudible 00:02:41] patient. And the red dots you'll see there represents the high distortion area. And here are the images, and you see the high distortion areas is periphery, it is at the periphery of the brain. But if the MR image, if the maintenance of your MR image in your hospital doesn't get regularly, your MRI images can be very distorted. So, I want to show you a video right now, it will automatically run. You see here the T2 and CT of the patient. You see here the discrepancy of the bony borders in the temporal region. So, when we order the computer elements to do the distortion correction, we will see the result. You see here, the red dots which has the more distortion, and the window going to that area. And you see this is better than before. So, of course the level, of course the measurement is so low. But we have to correct it, because we want to be very precise.
So, for example, in this patient, I hope you can see it from there. We have two sets of images here. In the first set, in the upper set, you see the original MR of the patient with the drawing of the tumor. It's a hemangioblastoma patient. And in the bottom line, you'll see the distortion corrected MR and the original drawing on that MR. You see some part of the tumor on the back side on the posterior side is missing. And if I irradiated this patients original MR I would miss some part of the tumor here. This side, you see?
Another patient with residual vestibular schwannoma after surgery. The upper set shows us the original MR with drawing of the tumor. The lower set shows that the drawing depending on the original set is different than the drawing in the distortion corrected MR. So, if I irradiated the original MR, I would miss some part of the real placement of the tumor.
Another patient, same thing, I could miss the part of the tumor, if I don't do a distortion correction. This is a patient with breast cancer metastases to cerebellum. And the blue line shows me the outlining of the tumor depending on the original MR. And the red line shows us the outline of the tumor depending on the distortion corrected one. From the sagittal image and the coronal image, you can see the difference.
The next topic will be the target definition-contouring anatomical atlas-organ at risk definition. To do target definition Gamma Knife radiosurgery, I mean GammaPlan, takes maybe two, five minutes. Of course, if you have a very complex skull-based meningioma, it may take maybe 10 minutes to draw the tumor correctly. But with an Element's [SP] 3D brush, it takes only one minute. I will show you a video.
And also, organ at risk definition depends on the image that you want to draw organ at risk. You may want to draw one organ, for example, only one optic nerve, or you may want to draw all the important structures in the brain. It takes time. But with Element, you can do it in less than five minutes. And in this video, you will see there as a meningioma here, you see? It's very easy, very straightforward. You can draw the tumor from the axial section. Then you can use coronal or sagittal, which one you want. Then you will see the 3D image of the tumor, and all slices can be reviewed. If you see any problem there, you can correct it. And it's very easy, because it takes time with GammaPlan.
But you must be very careful, because in this patient with a small meningioma in the parasellar area, it was compressing the left optic nerve. You see? I wanted to see the left optic nerve, because I want to spare it from the radiation effect. So, I wanted Element to draw the left optic nerve, but I think you can see here, the blue line here is in the tumor. So, for these kinds of small areas, small tumors with tiny optic nerves, Element may not see the exact position. Of course, to see the optic nerve there is also hard for me. And it is hard for Element too.
This is the treatment plan of this patient. But for the large area, for example, brainstem in a petroclival meningioma patient, it's easy to draw it by Element. And you can export all these structures to your GammaPlan and use it there. For example, this is a picture from GammaPlan. And you can see here the optic nerve is here, which is drawn by Element. And the tumor is here and the brainstem is there.
And this is the treatment plan of the patient. Other issue which we can use for GammaPlan is about radiation necrosis and adverse radiation effect. Of course, it is very important to differentiate between necrosis and the tumor recurrence. We don't want to irradiate the necrotic tissue, necrotic brain, necrotic tumor. Of course, we have many MR sequences, different techniques, to differentiate between tumor recurrence and necrosis.
Yesterday, we listened to a perfect presentation from one of our friends. And we can use contrast clearance system or TRAM for our patient's treatment. Roughly, and to remind you, only I will say that, I don't...I'm not going to go very deep. The blue areas which we see in TRAM is living tumoral tissue, and the red is necrotic tissue. I want to show you two case examples. One of them is a 53-year-old male with lung cancer. He came to stage with this multiple metastases. And in another hospital, they decided to give whole-brain radiotherapy to him. And after six months, six months later, his confirmed MRI image and TRAM contrast clearance showed this image.
So here, this is the pre-radiotherapy image. And today, you see the tumor in the cerebellum is in TRAM image. The part of the tumor is living tumoral cells, but most part of the tumor is necrotic. For other tumor, the second tumor, you see on the temporal lobe, it is mostly necrotic. But the periphery of the tumor here is living, has living tissue. Okay? So we have to target this area. And for the other tumor here, you see, it has some necrotic areas, but it's mostly viable tissue there, viable tumor tissue there. So we irradiated the tumor areas, the blue areas with Gamma Knife. And three months later, we had a second TRAM examination for this patient.
You see, it was three months ago. And now you see, all the tumoral area is red, is necrotic. So, for this temporal tumor, the same, old area is necrotic. And this is same for this one. But we did see another tumor in the cerebellum, which has necrotic part, plus tumoral part, okay, living tumoral tissue. So, we only irradiated that the tumoral part, which is close to tentorial in this patient.
This is the second case. She's 45 years old female with breast cancer. Had whole-brain radiotherapy for multiple metastases now at the hospital. And one year later, she came to us with new metastases. And we get the TRAM examination for this patient too. You see here? The tumor...and the TRAM shows us that it is completely blue. So, it is a living tumor there. So let's see this one. There is a tumor here. And with TRAM, you see, it is completely blue. So, we have to do something for that tumor too.
This is interesting. You see here, two parts, this part, another part here, you see? In TRAM, you see the medial part is necrotic. But the lateral part of the tumor is living. There's a recurrence. So, we have to target that part only. And also she has some other tumors of course, but those tumors demonstrated necrosis in TRAM. So, we don't need to target them in our Gamma Knife treatment. So, we irradiated all these three tumors that we see in TRAM.
And the last thing I would like to share with you, AVM treatment. And of course, other speakers talked here, said the same thing. The nidus definition in AVM is very important. And it differs from author to author. If we all people here see same MR and angiography image in the same...from same patient, we will draw the nidus differently. So, it's very important. So I would recommend for the newbies, don't begin with AVM radiosurgery, begin with metastases radiosurgery, for example. Where to irradiate and where is the nidus is very important in AVM radiosurgery. The traditional way in Gamma Knife radiosurgery, we were applying the frame on the patient's head. Get MR imaging, get stereotactic angiography and do the planning and do the treatment.
Is MR necessary? Yes, it is necessary. We have to do it. But if a patient has incompatible indication for MR, you can get CT. Is stereotactic DSA necessary? For frameless AVM treatment, for many years, we know that these features we can target the AVM with new Smart Brush of Element, you can do it without frame. So, you need T1 contrast or TOF MR image of the patient, and of course, diagnostic angiography of the patient. When you import these to the computer, you will see the branches of the vessels in the brain, and you have to combine them, the DSA and image from the MR. Then for these small ion, for these small AVMs, you can see the target. And you can draw the target from the Element, then send it to the GammaPlan and you can do your treatment there.
Another patient with an occipital, you see here, the images. And this is the treatment plan of the patient. And you see here, I didn't use stereotactic angiography in this patient. As a conclusion, I would say that there are many options to improve radiosurgical treatment for our patients, and to improve the success of the treatment and quality of life. We have to use these technological improvements. Thank you very much.