[Stereotactic one-time irradiation (radiosurgery). The methods, indications and results].

BACKGROUND: Stereotaxy is a method to determine a point in the patient's body by an external coordinate system which is attached to the patient. Radiosurgery uses this method for precise delivery of a high single radiation dose to the patient. The aim is to destroy the tissue in the target and to spare surrounding unaffected normal tissue by a steep dose gradient.

METHODS: Three techniques of percutaneous radiosurgery are available: radiosurgery with ion beams with a cyclotron, spherical arrangement of cobalt-60 sources, the so-called gamma knife, and an adapted linear accelerator. The availability and the good clinical experience lead to a wide spread use of linear accelerator for radiosurgery in recent years. A subsequent development is fractionated stereotactic radiotherapy which combines the precision of radiosurgery with the radiobiological advantage of fractionation.

RESULTS: Only a few indications for radiosurgery are proven by statistically valid studies. One of these is the treatment of small arteriovenous malformation, where obliteration rates of 80% to 100% are reported with only minor toxicity. However, the obliteration rate is reduced significantly in large arteriovenous malformations. A local control rate of 90% is obtained after radiosurgery of brain metastases which is comparable to the results of microsurgical resection followed by adjuvant whole brain radiotherapy. An ongoing EORTC study evaluates the role of adjuvant whole brain radiotherapy after radiosurgery. The survival of the patients with brain metastases is limited by the existence of progressive extracerebral disease. The role of radiosurgery in the treatment of benign tumors is currently evaluated in clinical studies which include: vestibular schwannomas, meningiomas, chordomas and chondrosarcomas and pituitary adenomas. Most of the published studies include only small tumors because radiosurgery is limited by the risk of radionecrosis of adjacent normal tissue, which shows a steep dose volume response relationship. Recent developments of stereotactic radiotherapy include the use of mini-multileaf-collimators and clinical studies on stereotactic radiotherapy of extracranial targets.

CONCLUSIONS: Stereotactic irradiation is a well established treatment technique for intracranial tumors and arteriovenous malformations. Methods are available that allow optimization of dose distributions to irregularly shaped tumors for single dose as well as fractionated stereotactic irradiations by linear accelerator. Therefore the therapeutic potential of this technique has increased and enables also the extracerebral application in controlled clinical studies.