Radiation therapy may be administered externally (i.e., a beam of radiation is directed into the body) or internally (i.e., a radioactive source is placed inside the body, near a tumor). External radiotherapy (RT) techniques include "conventional" or 2-dimensional (2D) RT, 3-dimensional (3D) conformal RT, and intensity-modulated radiation therapy (IMRT).
Conventional External-Beam Radiotherapy
Methods to plan and deliver RT have evolved that permit more precise targeting of tumors with complex geometries. Conventional 2D treatment planning utilizes X-ray films to guide and position radiation beams. Bony landmarks bones visualized on X-ray are used to locate a tumor and direct the radiation beams. The radiation is typically of uniform intensity.
Three-Dimensional Conformal Radiotherapy
Radiation treatment planning has evolved to use 3D images, usually from computed tomography (CT) scans, to more precisely delineate the boundaries of the tumor and to discriminate tumor tissue from adjacent normal tissue and nearby organs at risk for radiation damage. Three-dimensional conformal RT (3D-CRT) involves initially scanning the individual in the position that will be used for the radiation treatment. The tumor target and surrounding normal organs are then outlined in 3D on the scan. Computer software assists in determining the orientation of radiation beams and the amount of radiation the tumor and normal tissues receive to ensure coverage of the entire tumor in order to minimize radiation exposure for at risk normal tissue and nearby organs. Other imaging techniques and devices such as multileaf collimators (MLCs) may be used to "shape" the radiation beams. Methods have also been developed to position the individual and the radiation portal reproducibly for each fraction and to immobilize the individual, thus maintaining consistent beam axes across treatment sessions.
IMRT is the more recent development in external radiation. Treatment planning and delivery are more complex, time-consuming, and labor-intensive for IMRT than for 3D-CRT. Similar to 3D-CRT, the tumor and surrounding normal organs are outlined in 3D by a scan and multiple radiation beams are positioned around the individual for radiation delivery. In IMRT, radiation beams are divided into a grid-like pattern, separating a single beam into many smaller "beamlets". Specialized computer software allows for "inverse" treatment planning. The radiation oncologist delineates the target on each slice of a CT scan and specifies the target's prescribed radiation dose, acceptable limits of dose heterogeneity within the target volume, adjacent normal tissue volumes to avoid, and acceptable dose limits within the normal tissues. Based on these parameters and a digitally reconstructed radiographic image of the tumor, surrounding tissues, and organs at risk, computer software optimizes the location, shape, and intensities of the beam ports to achieve the treatment plan's goals.
Summary of Evidence
For individuals who have malignant brain tumors who receive IMRT, the evidence includes dose-planning studies, nonrandomized comparison studies, and a systematic review. Relevant outcomes are overall survival (OS), disease-specific survival (DSS), morbid events, functional outcomes, and treatment-related morbidity. Study results have consistently shown low radiation toxicity but have not demonstrated better tumor control or improved survival with IMRT. Dose-planning studies have shown that IMRT delivers adequate radiation doses to tumors while simultaneously reducing radiation exposure to sensitive brain areas. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have benign brain tumors who receive IMRT, the evidence includes case series. Relevant outcomes are OS, DSS, functional outcomes, and treatment-related morbidity. Case series results have consistently shown low radiation toxicity but have not demonstrated better tumor control or improved survival with IMRT versus other RT techniques. It is expected that the dose-planning studies evaluating IMRT in individuals with malignant tumors should generalize to individuals with benign brain tumors because the benefit of minimizing radiation toxicity to sensitive brain areas is identical. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have brain tumor metastases who receive IMRT to avoid hippocampal exposure, the evidence includes a randomized trial, nonrandomized studies, and case series. Relevant outcomes are OS, DSS, functional outcomes, and treatment-related morbidity. One (1) randomized trial and one (1) prospective nonrandomized comparison study using IMRT to avoid hippocampal exposure showed less cognitive decline with IMRT than with either conventional whole-brain radiotherapy or prespecified historical controls. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.