Case description

The patient is a 79-year-old woman with a 3-year history of non–small cell lung carcinoma, status post right upper lung lobectomy. She presented with episodes of progressive nausea and vomiting and was found to have diabetes insipidus. Imaging revealed a 1-cm enhancing lesion in the suprasellar region, adjacent to the optic chiasm and hypothalamus ( Figure 4.19.1 ). A stereotactic biopsy ( Figure 4.19.2 ) confirmed the diagnosis of a non–small cell lung metastasis, and the patient elected for stereotactic radiosurgery (SRS) ( Figure 4.19.3 ).

Preoperative postcontrast axial, sagittal, and coronal imaging showing a 10-mm enhancing lesion on the undersurface of the optic chiasm and hypothalamus with a slight local mass effect, as well as mass effect onto the recess of the third ventricle.

Preradiosurgery, postcontrast axial, sagittal, and coronal imaging following biopsy demonstrating a 7-mm enhancing suprasellar mass. Significant motion artifact is noted.

Imaging of the treatment plan.

Critical Structure	Dose Tolerance
Optic nerve/chiasm	<5 Gy maximum point dose
Brainstem	15 Gy maximum point dose <1 cc >10 Gy
Cranial nerves in cavernous sinus	Unknown but significantly more resistant than optic nerve Can be more sensitive if stereotactic radiosurgery (SRS) follows another form of radiation
Cavernous carotid artery	Very tolerant No evidence of SRS-induced stenosis

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