Frameless MLC-Based Radiosurgical Thalamotomies on the Modern Linear Accelerator Platform - Prospective Phase I/II Clinical Trial Results
Abstract
PURPOSE/OBJECTIVE(S)
Stereotactic radiosurgery (SRS) to the ventral intermediate nucleus (VIM) of the thalamus has been used with success to manage tremor in select patients. Because of the high doses, small target, & required precision, a non-invasive stereotactic radiosurgery instrument has been the historical choice platform. Our institution recently developed a technique to replicate functional SRS GK dose distributions on a multi-leaf collimator (MLC)-equipped linear accelerator (LINAC) without cumbersome, inefficient cones. We deployed this technique & tested it in a prospective clinical trial of safety & efficacy of SRS thalamotomy for non-DBS candidate patients with medically refractory essential or Parkinsonian tremor.
MATERIALS/METHODS
We quantified pre-treatment tremor according to FTM/PROMIS scores. We generated MPRAGE, FGATIR, diffusion-weighted tractographic, & resting-state fMRI sequences. We identified the VIM via both thalamic parcellation & classical stereotactic reference location, & targeted it to 130Gy dmax in a fashion dosimetrically equivalent to 4.5mm GK shot. We adjusted each target such that the 25Gy isodose line did not overlap the posterior limb of the capsule. We immobilized patients in a highly rigid thermoplastic mask. We delivered treatment with a LINAC with high-definition HDMLC & intrafraction optical surface monitoring (OSMS) to ensure patient immobility. We surveilled post-treatment imaging and tremor scores.
RESULTS
We accrued 32 patients…
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