title: Re-irradiation with hypo-fractionated stereotactic robotic radiotherapy for salvage in adult patients with brainstem glioma.
abstract: OBJECTIVE
  Brainstem glioma (BSG) is often treated with definitive irradiation. However, subsequent progression and death occur as a rule rather than the exception, after varying periods of control. The outlook of patients with post-irradiation progression is dismal, and most of these patients are treated with supportive care alone. Despite the obvious risks with an area as critical as the brainstem, it is a possibility to encounter situations wherein the patients (themselves or their associates) ask for re-irradiation, with the hope of a few extra months of life. The risk of radiation-induced brainstem toxicity may be justifiable under the strict assumption that the patients stand a chance of benefiting from re-irradiation but still may not live long enough to manifest brainstem toxicity.
  
  
  METHODS
  Five adult BSG patients were treated with re-irradiation using robotic-arm stereotactic radiation therapy (SRT) between September 2009 and July 2012, primarily at the request of the concerned patient parties. Re-irradiation doses ranged from 16 to 25 Gray (Gy) delivered by robotic arm stereotactic irradiation in 2-5 fractions.
  
  
  RESULTS
  Four out of five patients enjoyed a prolongation of survival in the order of months (three, five, six, and 14 months), which was very significant given that all patients had severe neurological compromise and poor performance status prior to re-irradiation. One patient has survived 36 months after re-irradiation and thus has lived long enough to manifest late radiation-induced brainstem toxicity.
  
  
  CONCLUSIONS
  Despite the obvious risks of brainstem toxicity associated with the use of re-irradiation for BSG, the use of fractionated stereotactic re-irradiation seems to offers prospects of additional periods of local control and augments duration of life.
authors.affiliation: HealthCare Global - Bangalore Institute of Oncology, Bangalore, Karnataka 560027, India.
authors.forename: Sridhar P
authors.initials: SP
authors.lastname: Susheela
authors.forename: Swaroop
authors.initials: S
authors.lastname: Revannasiddaiah
authors.forename: Sandeep
authors.initials: S
authors.lastname: Muzumder
authors.forename: Govindarajan
authors.initials: G
authors.lastname: Mallarajapatna
authors.forename: Kumar
authors.initials: K
authors.lastname: Kallur
authors.forename: Ajaikumar S
authors.initials: AS
authors.lastname: Basavalingaiah
keywords: adult brainstem glioma; brainstem glioma; hypofractionated; re-irradiation; reirradiation of brainstem glioma; stereotactic