Advanced Neuroimaging for Advanced Radiation Therapy

This special edition, entitled “Advanced Neuroimaging for Advanced Radiation Therapy” is jointly edited by radiation oncologists and radiologists. Our focus is on cross-education in the principles and innovations of both fields for a close interdisciplinary approach in the management of central nervous system (CNS) tumors, leveraging advanced imaging and state-of-art radiation therapy. For TMRI readers, this special edition intends to serve as a new educational platform to mutually benefit radiologists and radiation oncologists by providing updates on the rapid advancements in both fields. These concepts are essential to appreciating the synergistic capabilities of radiology and radiation oncology in treatment when combining the expertise from both fields and facilitating optimal communication to provide the highest quality and most effective care to our patients. After the departure of radiation oncology from diagnostic radiology a few decades ago, both our specialties have developed and have been practicing in their separate ways. This separation occurred when imaging modalities and radiation treatment options were far less sophisticated and complex than today. With the rapid advancement of shared technological capabilities and IT developments in both radiology and radiation oncology it has become clear that the trend of separation has spawned a new and strong relationship among our fields. Radiation oncologists and radiologists are working more closely than ever before and rely on each other in order to translate advanced imaging capabilities into high-precision radiation treatment delivery, and to advance our understanding and imaging interpretation of pre-radiation therapy and post treatment outcomes (pp. 35–101). Advancements in imaging modalities, image resolution, and post-processing have drastically improved the structural delineation and characterization of tumors. Functional imaging has enhanced neuro-radiation oncology's personalized medicine approach by improving the assessment of prognostic factors and imaging-based tumor heterogeneity, thus enabling heterogeneity-based radiation dose painting, response assessment, and individualized outcome prediction. In parallel, fueled by the same rapid advances in radiation therapy delivery and information technologies, high spatial resolution multi-modality imaging-based tumor delineation has enabled highly-targeted treatment planning, dose conformity, and radiation treatment delivery that achieves up to millimeter-precision. Such technical advancements have opened the door to delivering targeted radiation therapy to much higher, and thereby more effective, doses via advanced radiation therapy delivery techniques, initially with brain stereotactic radiosurgery (Gammaknife) and soon followed by fractionated stereotactic radiation (FSRT) and stereotactic body radiation therapy (SBRT). Particle beam therapy has further broadened the field into a new dimension, not only achieving higher precision but also higher biological effectiveness of radiation.1,2 These capabilities have resulted in higher response and tumor control rates, enabled the treatment of previously untreatable lesions, reduced treatment-related side effects and improved the quality of life in many patients with neurological tumors. Much of this extraordinary progress over the last decade is owed to the formidable advances in tumor imaging. Yet, these new imaging capabilities demand effective translation, communication, and a team-based approach among radiologists and radiation oncologists. Given the fundamental importance of targeting tumors with high precision while simultaneously avoiding radiation injury to normal tissues, radiologists should also be familiar with the significance of critical normal structures in the context of treatment planning and post-treatment imaging, such as adjacent spinal cord, cranial nerves, parahippocampal gyrus (cognitive sparing), red bone marrow (anemia), or stem cell regions (repairing of radiation injury), in order to minimize the radiation dose to these areas.3–6 Through the application of these principles, better protection of nearby normal tissues and simultaneous delivery of much higher radiation doses to primary or metastatic neurological tumor lesions located in the brain, neck, and spine, becomes realistic. The close multidisciplinary relationship between radiologists and radiation oncologists and their mutual roles in patient care is more critical than ever to providing optimal treatment that encompasses the most recent advances in cancer treatment. Imaging-guided radiation therapy, in conjunction with high-dose ablative stereotactic treatment delivery, has placed new demands on both of our specialties. Diagnostic imaging questions are now intermingled with those related to tumor target delineation and highly specific criteria for tumor response, many of which have yet to be elucidated. The high ablative-dose treatment poses further demand on the quality of treatment delivery and tumor imaging in order to avoid potentially severe toxicities from treatment, including death. Such complications have been a painful and deadly chapter in radiation oncology's technological leap from 3D conformal to intensity-modulated delivery.7 A detailed understanding of the pretreatment, on-treatment, and post-treatment imaging findings is crucial to radiation oncologists and guides necessary therapeutic interventions. Likewise, an understanding by neuroradiologists of the confounding myriad of advanced radiation oncology techniques employed in the treatment of neurological tumors, and the specific imaging needs, is key to delivering effective care that maximizes imaging and therapy capabilities for optimal patient outcome. This Special Edition of TMRI aims to provide a comprehensive and succinct discussion of the radiologic and radiotherapeutic state-of-art and leading-edge aspects for the most common neurological primary and metastatic tumors. The topic leaders for the second article, What Neuroradiologists Need to Know About Radiation Treatment for Neural Tumors (pp. 37–47), are Drs. Yolanda D. Tseng and Upendra Parvathaneni from University of Washington (UW), both radiation oncologists who are experts in brain tumors and head and neck cancer, respectively. Together, their article covers the basic principles of radiation therapy and critical imaging information needed by radiologists and radiation oncologists in the treatment of “tumors above the neck” (brain and head and neck tumors) in the context of the principles of brain and head and neck radiation therapy. The topic leader for the third article, The Role of Particle Therapy for the Treatment of Skull Base Tumors and Tumors of the Central Nervous System (CNS) (pp. 49–61), is Dr. Stephanie E. Combs, Professor and Chair of the Department of Radiation Oncology, Technical University in Munich (TUM). Dr. Combs is a recognized expert in particle therapy including carbon, proton and neutron therapy. She is one of the few physicians with broad experience in all modern techniques of radiation oncology. A key focus of her research is optimization of treatment of brain and skull base tumors. This experience and research focus provides the unique knowledge base for the third article. An understanding of principles of particle therapy is important, particularly for radiologists who may not be familiar with these still emerging, relatively rare technologies that have been increasing their footprint. This article provides broad discussion of the common radiation oncology terminology, and the contrast between the conventional photon and particle beam radiation therapies. The article leverages viewpoints from a broad range of specialties (radiology, radiation oncology, diagnostic, and therapeutic physicists) from multiple institutions to discuss these relatively unconventional, complex and costly aspects of particle therapies as clinical radiation therapy modalities. The leader for the fourth article, Neuroimaging for Radiation Therapy of Brain Tumors (pp. 63–71), is Dr. Anca L. Grosu, Professor and Chair of the Department of Radiation Oncology, University of Freiburg, Freiburg, Germany and member of the German National Academy of Sciences - Leopoldina. Dr. Grosu is among the few most qualified investigators and clinicians spanning our specialties: neuroradiology, nuclear medicine and radiation oncology. Her exceptional dual expertise, bridging between diagnostic neuroimaging and radiation oncology, provides her a unique and invaluable perspective for this topic. The topic leader of the fifth article, Updates in the Neuoroimaging and WHO Classification of Primary CNS Gliomas: A Review of Current Terminology, Diagnosis, and Clinical Relevance From a Radiologic Prospective (pp. 73–84), is Dr. James Fink, Associate Professor and Neuroradiology Fellowship Director at UW. The goal of this topic is to augment Dr. Grosu's article on brain tumors (fourth article) by outlining a simplified algorithm for diagnosis that encompasses the rapidly evolving field of tumor genomics as portrayed in the newest WHO Classification of CNS tumors. Through a systematic approach to morphological and imaging features, this article aims to render the most recent terminology more accessible to radiologists and trainees whose primary practice is not neuro-oncology. The leaders for the sixth article, Neuroimaging and Stereotactic Body Radiation Therapy (SBRT) of Spine Metastasis (pp. 85–96), Drs. Majid Khan, Kristin Redmond, and Simon Lo, designed and coordinated the experts from John Hopkins, University of Toronto, and UW to contribute to this broad and leading-edge field. The high incidence of spine metastases in cancer patients underscores the clinical relevance of spine SBRT, a field that is still relatively new for readers, particularly the concepts of standardized image interpretation for tumor delineation and spinal cord compression grading systems. Compared with conventional radiation therapy, spine SBRT has a high success rate in control of pain, tumor progression and neurological symptoms, and has become an important option for the noninvasive management of spine metastasis. It is important for radiologists to be familiar with, e.g. the Bilsky imaging grading system, a more standardized imaging interpretation which assesses the extent of metastasis, including epidural involvement and its spatial relationship to the thecal sac and spinal cord. Radiologists must be familiar with such grading scale systems that provide important information in determining patients’ eligibility for SBRT treatment. We hope this Special Edition will provide you with comprehensive new information that supports and advances your clinical practice, inspires innovation, and most of all, a mutual understanding and enhanced collaboration among our specialties.

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