title: Reirradiation of multiple brain metastases with helical tomotherapy. A multifocal simultaneous integrated boost for eight or more lesions.
abstract: OBJECTIVE
  : Recurrent brain metastases or new brain lesions after whole-brain radiotherapy represent a therapeutic challenge. While several treatment methods for single or few lesions have been described, options for multiple lesions are limited. This case report is intended to show an approach of whole-brain reirradiation with a simultaneous multifocal integrated boost using helical tomotherapy. Technique, feasibility, and acute side effects are presented.
  
  
  METHODS
  : Two patients with multiple relapsed brain metastases (eight and eleven lesions) were reirradiated after previous whole-brain radiotherapy (total dose of 40 Gy 18 months before). Whole-brain reirradiation was performed using helical tomotherapy with a total dose of 15 Gy (single dose 1.5 Gy) and a multifocal simultaneous integrated boost with a total dose of 30 Gy (single dose 3 Gy) to the brain lesions. The boost planning target volume was delineated around the lesions visible on MRI plus a 2-mm margin. Follow-up of these patients was 6 and 12 months.
  
  
  RESULTS
  : Radiation plans with excellent conformity and homogeneity were obtained. High dose exposure to normal brain tissue was kept minimal. Mean radiation time was 13 min. The only acute side effect observed was a mild headache over 2 days at the end of treatment. So far, no further side effects and no signs of recurrence have been observed.
  
  
  CONCLUSIONS
  : Helical tomotherapy offers new treatment options for the reirradiation of multiple brain metastases. The number of cases treated with the described protocol is very limited but it is considered a promising option for patients that have responded well to the initial radiotherapy and are in a good performance status.
authors.affiliation: Department of Radiation Oncology, University of Heidelberg, INF 400, 69120 Heidelberg, Germany. florian.sterzing@med.uni-heidelberg.de
authors.forename: Florian
authors.initials: F
authors.lastname: Sterzing
authors.forename: Thomas
authors.initials: T
authors.lastname: Welzel
authors.forename: Gabriele
authors.initials: G
authors.lastname: Sroka-Perez
authors.forename: Kai
authors.initials: K
authors.lastname: Schubert
authors.forename: Jürgen
authors.initials: J
authors.lastname: Debus
authors.forename: Klaus K
authors.initials: KK
authors.lastname: Herfarth
mesh_terms: D000328:Adult; D001932:Brain Neoplasms / Q000532:radiotherapy* / Q000556:secondary*; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020266:Radiotherapy, Conformal / Q000379:methods*; D016896:Treatment Outcome