title: A simple treatment planning strategy for patients with multiple metastases treated with Gamma Knife surgery.
abstract: OBJECTIVE
  In a substantial number of patients treated at the authors' facility for brain metastases, additional lesions are identified at the time of Gamma Knife surgery (GKS). These lesions are often widely dispersed and may number over 10, which is the maximal number of matrices that can be currently placed for treatment with Leksell Gamma-Plan 4C. The authors describe a simple planning method for GKS in patients with multiple, widely dispersed central nervous system (CNS) metastases.
  
  
  METHODS
  Two patients presented with three to five identified recurrent metastases from non-small cell lung carcinoma and breast carcinoma after having received whole-brain radiotherapy. At the time of treatment with GKS in each patient, spoiled-gradient Gd-enhanced magnetic resonance (MR) imaging revealed substantially more metastases than originally thought, which were widely scattered throughout all regions of the brain. The authors simplified the treatment planning approach by dividing the entire CNS contents into six contiguous, nonoverlapping matrices, which allowed for the planning, calculation, and treatment of all lesions. Two patients were successfully treated with GKS for more than 10 CNS metastases by using this simple planning method. Differing peripheral doses to varied-size lesions were delivered by prescribing to different isodose curves within any given matrix when required. Dose-volume histograms showed brain doses as follows: 10% of the total brain volume received 5 to 6.4 Gy; 25% received 3.8 to 4.8 Gy; 50% received 2.7 to 3.1 Gy; and 75% received 2.2 to 2.5 Gy.
  
  
  CONCLUSIONS
  The delineation of more metastases than appreciated on the diagnostic MR imaging is a common occurrence at the time of GKS at the authors' institution. The treatment of multiple (>10), widely dispersed CNS metastases can be simplified by the placement of multiple, contiguous, non-overlapping matrices, which can be employed to treat lesions in all areas of the brain when separate matrices cannot be utilized.
authors.affiliation: University of Washington Gamma Facility at Harborview, University of Washington, Seattle, Washington 89195-6043, USA. drjay@u.washington.edu
authors.forename: James G
authors.initials: JG
authors.lastname: Douglas
authors.forename: Robert
authors.initials: R
authors.lastname: Goodkin
mesh_terms: D001932:Brain Neoplasms / Q000556:secondary* / Q000601:surgery*; D001943:Breast Neoplasms / Q000473:pathology; D002289:Carcinoma, Non-Small-Cell Lung / Q000556:secondary* / Q000601:surgery*; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology; D008279:Magnetic Resonance Imaging; D016634:Radiosurgery; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*