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• W2007392505 abstract "Two encouraging articles in the current issue highlight the increasing use of stereotactic radiotherapeutic techniques (20) for treating intracranial tumors, either with the “gamma knife” (6), or with linear accelerators (21). It is now reasonably well established (12, 19) that stereotactic radiotherapy with only a single fraction, often called radiosurgery, represents a suboptimal treatment technique for treating tumors, compared with a fractionated treatment. This is true from the point of view of tumor reoxygenation, and also of sublethal damage repair of earlyand late-responding tissues. In short, it is to be expected that a single fraction (a) would be unable to sterilize a significant fraction of hypoxic tumor cells and (b) would effectively limit the tumor dose that could be delivered, due to induction of limiting late-responding normal-tissue complications. It should be noted that none of these arguments apply to arteriovenous malformations (AVM’s), which are probably adequately treated with a single fraction ( 12). The results in both papers in the current issue, while extremely promising, support the notion that even better clinical results are achievable with fractionation. Mendenhall et al. (2 1) used single-fractionated stereotactic radiotherapy to treat acoustic schwannomas; they were forced to reduce the prescribed dose due to unacceptable normal-tissue damage in the form of cranial-nerve deficit. Flickinger et al. (6) report a multicenter trial in which single-fraction radiosurgery, combined with fractionated external-beam radiotherapy, was used to treat solitary brain metastases. They reported a 2-year actuarial tumorcontrol rate of 67%. It seems likely that both trials could have benefited from fractionating the dose, either in terms of decreased late effects and/or improved tumor control. Flickinger et al. (6) perhaps recognize this, suggesting that fractionated large-field radiotherapy combined with singlefraction radiosurgery might be a logistically easier way to exploit fractionation, rather than using fractionated stereotactic radiotherapy. However, the development and commercial availability of practical relocatable stereotactic head frames (4, 8-10, 13-16,25, 27) now makes fractionated stereotactic radiotherapy a real option, maintaining the good dose distribution of radiosurgery, together with the biological advantages of fractionation. If fractionated stereotactic radiotherapy is to be used, the question arises as to how many fractions to use and in what overall time? [The issue of total dose has been addressed elsewhere (2).] Fractionation schemes that have been used in the clinic for stereotactic radiotherapy of intracranial tumors vary from “conventional” daily fractionation (1.8-2 Gy/day) used, for example, at the Joint Center for Radiation Therapy (5), and at the University of Miami (18, 26), to various types of accelerated hypofractionation such as at McGill University [six fractions in 2 weeks (3)], Vicenza, [two fractions in 1 week (22)], Royal Marsden Hospital [two to ten daily fractions (1, 17)], and Virginia Mason, Seattle [two to five daily fractions (23)]. Other than the need for some kind of fractionation, as of now, no clear rationale has been stated for the choice of fractionation scheme, although Clark et al. (3) suggest that their accelerated hypofractionation regimen (six fractions in 2 weeks) is “chosen for practical reasons, as a compromise between the large numbers of fractions used in standard radiotherapy, and dose delivery in a single session used in radiosurgery”. We suggest here that a scientific rationale does exist for choosing fractionation schemes for stereotactic radiotherapy of brain tumors. Withers et al. (29) and many" @default.
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• W2007392505 title "Stereotactic radiotherapy of intracranial tumors—An ideal candidate for accelerated treatment" @default.
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• W2007392505 doi "https://doi.org/10.1016/0360-3016(94)90126-0" @default.
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