This 46 years old gentleman plumber from Mizoram, who was infected with HIV infection (also has the habit of alcohol & smoking) was diagnosed to have hepatocellular carcinoma Right lobe of liver in January 2010. He underwent chemotherapy treatment & TACE treatment else where, still the disease persisted he came for cyberknife radio surgery in June 2010.
After assessing him with PET CT and other investigations, we decided to take him up for cyberknife radio surgery.
With help of our interventional radiologist. Patient underwent gold fiducial insertion into his lesion under image guidance, after 1 week, he was taken up for treatment planning and verification.
He was treated between 28/6/2010 to 3/7/2010 with five fractions of cyberknife radio surgery, he tolerated the treatment very well.
The whole procedure was done as out patient basis.
Patient came for his 1st follow up in October 2010, he was absolutely feeling better after the treatment with steady improvement in his health.
PET CT in October 2010 showed complete resolution of lesion.
Both patient and we (doctors) are very happy to see the good result.
For further information ,you may please blog your comments are write to lakshmipriya_b@apollohospitals.com
Wednesday, December 15, 2010
Sunday, October 10, 2010
organ preserving treatment for small localized choroid melanoma
Title: Radiosurgery with CyberKnife as an organ preserving treatment for small localized choroid melanoma
Authors: KR Prasanna Kumar*, MBBS; Debnarayan Dutta*, MD; Prativa Mishra^, MS; Raghunandhan* MD; P Mahadev * MD, DNB; AN Vaidhyswaran* MD; Sanjay Chandrasekhar* MD; Janos Stumpf *MD, PhD; Rathnadevi* DMRT; V Murali# PhD; PG Kurup# PhD;
*Department of Radiation Oncology, #Medical Physics, Apollo Speciality Hospital, Chennai
^Department of Opthalmology, Apollo Speciality Hospital, Chennai
Abstract
Aim: To evaluate robotic radiosurgery as an organ preserving treatment for localized choroid melanoma of the eye.
Case report: Thirty six year old female patient had complaint of progressive dimness of vision of right eye for six months. Fundoscopy examination showed small lesion (2.5 x 2.5 mm) in macular region. 320 slices CT scan showed organ confined 2.5 x 2.5 mm nodular lesion in the macular region (3 mm superior and 2.5 mm temporal to the origin of optic nerve at fovea) of right eye and was diagnosed with localized choroid melanoma of right eye (visual acuity 6/18 ). Metastatic workup was normal. She was planned for SRS (CyberKnife) as an organ preserving approach. Planning CT scan and CyberKnife treatment (dose 18 Gy single fraction, prescription isodose 85%; treatment time 22 min, GTV 111.6 mm3, 2mm PTV margin, PTV 403 mm3) were done with retro-bulbar anesthesia. Mean dose to right eye, left eye, right eye lens and pituitary gland was 4.9, 0.4, 0.4 and 1 Gy respectively. Maximum dose to optic chiasm, brainstem, right (2% vol) and left optic nerve were 1.4, 2.1, 15 and 0.4 Gy respectively. Skull tracking method was used as tumour tracking method. She completed treatment without any acute complication and visual acuity was preserved.
Conclusion: Robotic radiosurgery is a feasible, acceptable and an appropriate treatment modality as organ preserving approach in small choroid melanomas.
Keywords: Choroid melanoma, Robotic radiosurgery, Organ preserving approach
Authors: KR Prasanna Kumar*, MBBS; Debnarayan Dutta*, MD; Prativa Mishra^, MS; Raghunandhan* MD; P Mahadev * MD, DNB; AN Vaidhyswaran* MD; Sanjay Chandrasekhar* MD; Janos Stumpf *MD, PhD; Rathnadevi* DMRT; V Murali# PhD; PG Kurup# PhD;
*Department of Radiation Oncology, #Medical Physics, Apollo Speciality Hospital, Chennai
^Department of Opthalmology, Apollo Speciality Hospital, Chennai
Abstract
Aim: To evaluate robotic radiosurgery as an organ preserving treatment for localized choroid melanoma of the eye.
Case report: Thirty six year old female patient had complaint of progressive dimness of vision of right eye for six months. Fundoscopy examination showed small lesion (2.5 x 2.5 mm) in macular region. 320 slices CT scan showed organ confined 2.5 x 2.5 mm nodular lesion in the macular region (3 mm superior and 2.5 mm temporal to the origin of optic nerve at fovea) of right eye and was diagnosed with localized choroid melanoma of right eye (visual acuity 6/18 ). Metastatic workup was normal. She was planned for SRS (CyberKnife) as an organ preserving approach. Planning CT scan and CyberKnife treatment (dose 18 Gy single fraction, prescription isodose 85%; treatment time 22 min, GTV 111.6 mm3, 2mm PTV margin, PTV 403 mm3) were done with retro-bulbar anesthesia. Mean dose to right eye, left eye, right eye lens and pituitary gland was 4.9, 0.4, 0.4 and 1 Gy respectively. Maximum dose to optic chiasm, brainstem, right (2% vol) and left optic nerve were 1.4, 2.1, 15 and 0.4 Gy respectively. Skull tracking method was used as tumour tracking method. She completed treatment without any acute complication and visual acuity was preserved.
Conclusion: Robotic radiosurgery is a feasible, acceptable and an appropriate treatment modality as organ preserving approach in small choroid melanomas.
Keywords: Choroid melanoma, Robotic radiosurgery, Organ preserving approach
Monday, July 12, 2010
Rectal Carcinoma with Lung Metastasis
Rectal Carcinoma with Lung Metastasis
Case History
A 77-year-old male was presented to Apollo Speciality Cancer Hospital reporting rectal carcinoma that was diagnosed in the year 2006. The patient was then undergone surgery (anterio perineal resection), radiation therapy and chemotherapy. The patient was clinically stable until the year 2009. In the year 2009, he developed repeated episodes of cough and pain on the right side of the chest. Owing to these complaints, the patient was evaluated by performing whole body PET scan. The scan revealed increased metabolic activity in lower lobe of the right lung and posterior basal segment pleural base mass. No other sight in the body showed activity (disease) in the PET scan. Biopsy from the lung mass was suggestive of metastatic adenocarcinoma.
The patient was diagnosed with solitary lung metastasis with controlled primary site disease and was planned to treat with radical intent using CyberKnife®. He was treated with 45Gy in five fractions in 1 week through CyberKnife® radiosurgery. The patient tolerated the radiosurgery well.
A follow-up CT scan was performed at 6-month post-CyberKnife®. The scan revealed a significant reduction in the lung mass.
Discussion
Generally, patients having solitary (single) or ‘oligo metastasis’ (<3 metastasis) with otherwise good general health and controlled primary disease are treated with curative intent. Surgery (metastectomy) is the preferred treatment. However, surgery may not be possible in a large
number of patients because of their medical condition or age. Therefore, these patients can be treated with radiosurgery using CyberKnife®
For more information you may please blog your comments or write to lakshmipriya_b@apollohospitals.com
Case History
A 77-year-old male was presented to Apollo Speciality Cancer Hospital reporting rectal carcinoma that was diagnosed in the year 2006. The patient was then undergone surgery (anterio perineal resection), radiation therapy and chemotherapy. The patient was clinically stable until the year 2009. In the year 2009, he developed repeated episodes of cough and pain on the right side of the chest. Owing to these complaints, the patient was evaluated by performing whole body PET scan. The scan revealed increased metabolic activity in lower lobe of the right lung and posterior basal segment pleural base mass. No other sight in the body showed activity (disease) in the PET scan. Biopsy from the lung mass was suggestive of metastatic adenocarcinoma.
The patient was diagnosed with solitary lung metastasis with controlled primary site disease and was planned to treat with radical intent using CyberKnife®. He was treated with 45Gy in five fractions in 1 week through CyberKnife® radiosurgery. The patient tolerated the radiosurgery well.
A follow-up CT scan was performed at 6-month post-CyberKnife®. The scan revealed a significant reduction in the lung mass.
Discussion
Generally, patients having solitary (single) or ‘oligo metastasis’ (<3 metastasis) with otherwise good general health and controlled primary disease are treated with curative intent. Surgery (metastectomy) is the preferred treatment. However, surgery may not be possible in a large
number of patients because of their medical condition or age. Therefore, these patients can be treated with radiosurgery using CyberKnife®
For more information you may please blog your comments or write to lakshmipriya_b@apollohospitals.com
Cholangiocarcinoma treated with CyberKnife
Cholangiocarcinoma treated with CyberKnife
Introduction: Cholangiocarcinoma is a relatively rare disease, however has poor prognosis. Liver resection or transplantation is only curative treatment (1). Unfortunately, majority of the patients present with locally advanced, unresectable disease with extensive tumor spread (2). The treatment is not yet standardized. They are treated with either chemotherapy or radiotherapy or in combination (2-6). CyberKnife is recent advancement in radiation therapy delivery system which has high accuracy and flexibility in targeting the tumor through image-guided stereotactic body radiotherapy (SBRT) system (7).
Case history: Forty eight year old gentleman from Uttar Pradesh, India was diagnosed with inoperable cholangiocarcinoma eight months back. He was treated with chemotherapy for four months. However, post-chemotherapy imaging evaluation did not show any significant response. He was diagnosed as chemo-resistant inoperable cholangiocarcinoma. His liver function was maintained and general condition was good. As he was suffering from inoperable, chemotherapy resistant cholangiocarcinoma, he was referred for radiation therapy and was evaluated for robotic radiosurgery (CyberKnife) treatment. After appropriate evaluation, imaging (PET scan), fiducial placement and planning he was treated with CyberKnife. He received 30 Gy in 5 fractions in one week. Dose to the target was adequate and to adjacent normal structures were within normal limits. He completed treatment without any severe toxicity and is on regular follow up.
Discussion: In early operable choloangiocarcinoma, 3-year overall survival rate after curative surgery is only 40-60% (1-2). Advanced unresectable cholangiocarcinoma patients have poorer prognosis as well as severe complications due to biliary stasis (3,4). They are mainly treated with supportive or palliative care. Main aims of treatment in these patients are to preserve quality of life and improve survival rate. Palliative therapy options in these patients are chemotherapy, radiotherapy, photodynamic therapy and biliary drainage procedures (5). Median survival with palliative chemotherapy and external beam radiation therapy are 5 to 9 and 9 to 12 months respectively (2-6). Inoperable, advanced cholangiocarcinomas remain localized and distant metastasis is not common (1). Hence, these tumours may be treated with localized treatment options with maximum effect. However, cholangiocarcinomas are relatively resistant to both radiation and chemotherapy. Hence, high dose radiation therapy is required to have desired loco-regional control (7). CyberKnife radiosurgery is a SBRT using real time respiratory-motion tracking system, and is known to exert minimal normal tissue injury. High dose of radiation treatment in few fractions are possible with CyberKnife which increases tumour control probability without increasing toxicity (7). High dose radiation therapy with proton beam therapy also has shown promising loco-regional control without additional severe toxicity (2). We suggest that CyberKnife might be a safe and useful treatment option in advanced, unresectible cholangiocarcinoma.
For more information you may please blog your comments or write to lakshmipriya_b@apollohospitals.com
Introduction: Cholangiocarcinoma is a relatively rare disease, however has poor prognosis. Liver resection or transplantation is only curative treatment (1). Unfortunately, majority of the patients present with locally advanced, unresectable disease with extensive tumor spread (2). The treatment is not yet standardized. They are treated with either chemotherapy or radiotherapy or in combination (2-6). CyberKnife is recent advancement in radiation therapy delivery system which has high accuracy and flexibility in targeting the tumor through image-guided stereotactic body radiotherapy (SBRT) system (7).
Case history: Forty eight year old gentleman from Uttar Pradesh, India was diagnosed with inoperable cholangiocarcinoma eight months back. He was treated with chemotherapy for four months. However, post-chemotherapy imaging evaluation did not show any significant response. He was diagnosed as chemo-resistant inoperable cholangiocarcinoma. His liver function was maintained and general condition was good. As he was suffering from inoperable, chemotherapy resistant cholangiocarcinoma, he was referred for radiation therapy and was evaluated for robotic radiosurgery (CyberKnife) treatment. After appropriate evaluation, imaging (PET scan), fiducial placement and planning he was treated with CyberKnife. He received 30 Gy in 5 fractions in one week. Dose to the target was adequate and to adjacent normal structures were within normal limits. He completed treatment without any severe toxicity and is on regular follow up.
Discussion: In early operable choloangiocarcinoma, 3-year overall survival rate after curative surgery is only 40-60% (1-2). Advanced unresectable cholangiocarcinoma patients have poorer prognosis as well as severe complications due to biliary stasis (3,4). They are mainly treated with supportive or palliative care. Main aims of treatment in these patients are to preserve quality of life and improve survival rate. Palliative therapy options in these patients are chemotherapy, radiotherapy, photodynamic therapy and biliary drainage procedures (5). Median survival with palliative chemotherapy and external beam radiation therapy are 5 to 9 and 9 to 12 months respectively (2-6). Inoperable, advanced cholangiocarcinomas remain localized and distant metastasis is not common (1). Hence, these tumours may be treated with localized treatment options with maximum effect. However, cholangiocarcinomas are relatively resistant to both radiation and chemotherapy. Hence, high dose radiation therapy is required to have desired loco-regional control (7). CyberKnife radiosurgery is a SBRT using real time respiratory-motion tracking system, and is known to exert minimal normal tissue injury. High dose of radiation treatment in few fractions are possible with CyberKnife which increases tumour control probability without increasing toxicity (7). High dose radiation therapy with proton beam therapy also has shown promising loco-regional control without additional severe toxicity (2). We suggest that CyberKnife might be a safe and useful treatment option in advanced, unresectible cholangiocarcinoma.
For more information you may please blog your comments or write to lakshmipriya_b@apollohospitals.com
Tuesday, June 8, 2010
Breast Carcinoma with Lung Metastasis
Breast Carcinoma with Lung Metastasis
Case History
A 44-year-old female diagnosed with carcinoma of the left breast in the year 2004 and was treated with mastectomy, chemotherapy and
radiation therapy was brought to Apollo Speciality Cancer Hospital. The patient was on hormonal therapy.
In the year 2006, the patient developed carcinoma of the contralateral breast (left) and had undergone surgery, followed by chemotherapy and radiation therapy to the left chest wall.
A PET scan was done in 2009. The scan revealed solitary metastasis in the lower lobe of the right lung. Owing to this, the patient was planned for CyberKnife® treatment. The patient was treated with 45Gy radiation dosage in three fractions to the lung lesion and had tolerated the treatment well. Complete response was seen in 3-month post-CyberKnife® follow-up scan
Discussion
Radiation therapy or surgery are frequently advised especially if chemotherapy is less efficient for patients suffering from single-lung metastasis.
However, as the lung mass moves with respiration, it is difficult to perform radiation therapy. Only respiratory-gated radiation therapy techniques deliver appropriate dose to the target and spare normal lung tissue. CyberKnife® has one of the most efficient respiratory tracking mechanisms (Synchrony) and this technology makes ‘real-time’ tracking possible by providing correct radiation dose to the tumour and avoiding the normal tissue in the vicinity. In addition, ‘See and Shoot’ technology in CyberKnife® helps to verify the target position prior to each treatment delivery and is the most accurate ‘online’ gated radiation therapy technique.
Doctor’s Comment
‘CyberKnife® is a fantastic option of providing the radiation therapy to the tumours which are mobile, like the one in this case. It avoids radiation exposure to normal tissue to a great extent.’
Dr. A. N. Vaidhyswaran
Patient’s Comment
‘I thought the treatment would be difficult, but the doctors at Apollo reassured me and they were true. The treatment was absolutely painless and I could go home immediately after the treatment’.
For more information on Cyberknife treatment you can blog your comments or write to lakshmipriya_b@apollohospitals.com
Case History
A 44-year-old female diagnosed with carcinoma of the left breast in the year 2004 and was treated with mastectomy, chemotherapy and
radiation therapy was brought to Apollo Speciality Cancer Hospital. The patient was on hormonal therapy.
In the year 2006, the patient developed carcinoma of the contralateral breast (left) and had undergone surgery, followed by chemotherapy and radiation therapy to the left chest wall.
A PET scan was done in 2009. The scan revealed solitary metastasis in the lower lobe of the right lung. Owing to this, the patient was planned for CyberKnife® treatment. The patient was treated with 45Gy radiation dosage in three fractions to the lung lesion and had tolerated the treatment well. Complete response was seen in 3-month post-CyberKnife® follow-up scan
Discussion
Radiation therapy or surgery are frequently advised especially if chemotherapy is less efficient for patients suffering from single-lung metastasis.
However, as the lung mass moves with respiration, it is difficult to perform radiation therapy. Only respiratory-gated radiation therapy techniques deliver appropriate dose to the target and spare normal lung tissue. CyberKnife® has one of the most efficient respiratory tracking mechanisms (Synchrony) and this technology makes ‘real-time’ tracking possible by providing correct radiation dose to the tumour and avoiding the normal tissue in the vicinity. In addition, ‘See and Shoot’ technology in CyberKnife® helps to verify the target position prior to each treatment delivery and is the most accurate ‘online’ gated radiation therapy technique.
Doctor’s Comment
‘CyberKnife® is a fantastic option of providing the radiation therapy to the tumours which are mobile, like the one in this case. It avoids radiation exposure to normal tissue to a great extent.’
Dr. A. N. Vaidhyswaran
Patient’s Comment
‘I thought the treatment would be difficult, but the doctors at Apollo reassured me and they were true. The treatment was absolutely painless and I could go home immediately after the treatment’.
For more information on Cyberknife treatment you can blog your comments or write to lakshmipriya_b@apollohospitals.com
Radiosurgical Treatment of Primary Liver Cancer: Baylor Radiosurgery Center Experience
Radiosurgical Treatment of Primary Liver Cancer: Baylor Radiosurgery Center Experience
John O’Connor, M.D., Medical DirectorBaylor Radiosurgery Center, Dallas, TXRobert Goldstein, M.D., Director, Liver and Pancreas Disease CenterBaylor University Medical Center, Dallas, TX
Hepatocellular carcinoma (HCC) is the fifth most common cancer and third leading cause of cancer death, with 626,000 new cases and 598,000 deaths per year.1 Although it is less common in the United States, its incidence has tripled in the past 30 years principally in relation to the spread of hepatitis C infection.2 Survival for patients with hepatocellular cancer remains poor, about 10% at 5 years.3 HCC is potentially curable with hepatic resection or transplantation, but fewer than 30% of patients are eligible for surgery.4,5 Liver transplantation is the primary treatment for patients with cirrhosis and unresectable HCC, with low rates of recurrence and 5-year survival of about 70%.6,7
Stereotactic body radiotherapy (SBRT) has the ability to deliver high, focused doses while limiting irradiation of normal liver tissue. The use of SBRT for both primary and metastatic liver cancer is increasing worldwide at an impressive rate as clinicians are encouraged by favorable safety and efficacy data.8-11 CyberKnife® researchers have been active in the use of SBRT for liver as well.12-14 At the Baylor Radiosurgery Center we have been treating unresectable HCC since April of 2005. In March 2010 we updated our findings at the CyberKnife Scientific Meeting in Dallas.
We presented outcomes of a retrospective review of 24 patients with 27 tumors. All patients were evaluated by a liver transplant surgeon prior to radiosurgery and were deemed unresectable. The median tumor diameter was 4 cm and we have successfully treated liver tumors as large as 11 cm in diameter. Patients were treated with the CyberKnife System using Synchrony® Respiratory Tracking. The median dose was 42 Gy (range 27 - 54 Gy) to the median 66% isodose line (range 50 - 80%), delivered in 3 daily fractions in 22 patients and 5 fractions in four patients. We followed our patients using MRI obtained at 3-month intervals.
To date our outcomes have been encouraging. Grade 1 or 2 toxicity (based on CTCAE 3.0 guidelines) occurred in four patients (17%); a single Grade 3 toxicity was observed. There were no Grade 4-5 toxicities and no occurrence of radiation-induced liver disease. Overall local tumor control in all patients based on RECIST criteria was 87% at a median follow-up of 12 months. One-year Kaplan-Meier survival was 43%, and median survival was 11 months.
An additional eight patients with HCC (and nine tumors) were treated as a “bridge” to liver transplantation, that is, to control the growth of their tumors so that they may remain on the organ waitlist until a liver is available for transplant. We presented our preliminary findings on these patients at the 2009 meeting of the American Society for Radiation Oncology (ASTRO).15 All of these patients proceeded to transplant in a median of 90 days (range 8 – 209 days) after radiosurgery. We assessed the tissue response in the explanted tissue; three of the lesions responded completely, three were reduced in size, and three were stable.
The CyberKnife System has become a valuable component of our treatment program for unresectable HCC. Its ability to track liver tumors as they move with respiration has allowed us to deliver high doses of radiation accurately to achieve excellent rates of local control.
Source: Accuray Newsletter April 2010
For more information you may please blog your comments or write to lakshmipriya_b@apollohospitals.com
Tuesday, May 11, 2010
Cerebellopontine Angle Haemangioblastoma Successfully
Cerebellopontine Angle Haemangioblastoma Successfully
Treated with CyberKnife®
Case History
A 15-year-old boy was presented to Apollo Speciality Cancer Hospital with complaints of neck pain, tingling sensation and weakness of upper limbs for the past 2 weeks. MRI of the brain and MR angiogram showed an expansile mass in the left cerebellopontine (CP) region. The patient was diagnosed with haemangioblastoma.
Craniotomy was planned as management measure. During the surgery, surgeons found that tumour was highly vascularised, adherent to medulla hence further surgical intervention was not done and patient was referred for CyberKnife®.
The patient was treated with CyberKnife® at a total dosage of 21Gy in three fractions (7 Gy/Fr) to the target. The patient tolerated the treatment well. A significant improvement in the clinical symptoms and a significant decrease in the contrast-enhancing solid mass were observed at third month following the treatment. Currently, the patient is doing well and is on regular follow-up.
DISCUSSIONS
Haemangioblastomas are low-grade tumours, which are seen in young patients and are characterised by signs related to increased intracranial pressure. Surgery is the mainstay of treatment and complete excision of the contrast-enhancing nodule along with cyst amounts to cure.Radiation therapy is required in situations where complete excision is not possible due to either location or size of the tumour. CyberKnife® is the most precise treatment in these situations. The regression treatment achieves of the mass, with minimal dose to the adjacent critical structures.w
Doctor’s Comment
‘In this patient, having CyberKnife® treatment in the armamentarium was a boon. Highly vascularised tumour, which was inoperable, could be managed successfully’.
Dr. R. Rathna Devi and Dr. Janos Stumpf
Patient’s Comment
‘This is a very good treatment. Painless and effective too’ith CyberKnife®
Saturday, April 24, 2010
WHOLEBODY STEREOTACTIC RADIO SURGERY " ON THE EIGHT OF MAY 2010.
APOLLO HOSPITALS IS CONDUCTING A WORKSHOP AND A SYMPOSIUM ON "WHOLEBODY STEREOTACTIC RADIO SURGERY " ON THE EIGHT OF MAY 2010.
WE INVITE RADIATION ONCOLOGISTS TO JOIN US IN THE SYMPSOIUM AND THE WORKSHOP
THE WORKSHOP WOULD BE AT APOLLO SPECIALITY HOSPITAL and THE SYMPOSIUM IS AT TAJ CONNEMARA STARTING FROM 7. 30 P.M
The Symposia is to share Apollo Cyberknife Clinical Experience with Panel discussion, where around ( 150 Medical / Radiation Oncologists & other Key Refering Specialists) will participate.
The Highlight for the event is the International Speaker , Dr. Andrew Gaya, London.
Dr Andrew Gaya BSc MD MRCP FRCR
Consultant Clinical Oncologist
Guy's & St Thomas' NHS Foundation Trust
Westminster Bridge Road
London SE1 7EH
FOR MORE INFORMATION YOU MAY PLEASE WRITE TO lakshmipriya_b@apollohospitals.com.
WE INVITE RADIATION ONCOLOGISTS TO JOIN US IN THE SYMPSOIUM AND THE WORKSHOP
THE WORKSHOP WOULD BE AT APOLLO SPECIALITY HOSPITAL and THE SYMPOSIUM IS AT TAJ CONNEMARA STARTING FROM 7. 30 P.M
The Symposia is to share Apollo Cyberknife Clinical Experience with Panel discussion, where around ( 150 Medical / Radiation Oncologists & other Key Refering Specialists) will participate.
The Highlight for the event is the International Speaker , Dr. Andrew Gaya, London.
Dr Andrew Gaya BSc MD MRCP FRCR
Consultant Clinical Oncologist
Guy's & St Thomas' NHS Foundation Trust
Westminster Bridge Road
London SE1 7EH
FOR MORE INFORMATION YOU MAY PLEASE WRITE TO lakshmipriya_b@apollohospitals.com.
Thursday, April 15, 2010
CYBERKNIFE -INTRACRANIAL TREATMENT REVIEWS
CYBERKNIFE -INTRACRANIAL REVIEWS
Source: http://www.accuray.com/clinicans/clinical-development/applications/clinical-publications.aspx#Reviews
Intracranial:
Staged stereotactic irradiation for acoustic neuroma. Chang et al. 2005. Stanford researchers show that fractionated treatment using the CyberKnife System for acoustic neuromas may improve hearing preservation.
Robotically guided radiosurgery for children. Giller, et al. 2005. Researchers from Baylor University Medical Center used the CyberKnife System to achieve local control for children with some types of CNS tumors.
Visual field preservation after multisession CyberKnife radiosurgery for perioptic lesions. Adler, et al. 2006. Stanford University researchers used the CyberKnife System to obtain high rates of tumor control for tumors near (less than 2 mm from) the optic apparatus; over 90% of patients treated maintained or improved their vision.
Stereotactic radiosurgery using CT cisternography and non-isocentric planning for the treatment of trigeminal neuralgia. Lim et al. 2006. Researchers from Stanford University used the CyberKnife System to treat trigeminal neuralgia. Ninety percent of patients treated rated their pain control as excellent with limited facial numbness at 10 months follow-up.
Stereotactic radiosurgery of the postoperative resection cavity for brain metastases. Soltys, et al. 2007. Researchers from Stanford University used the CyberKnife System for adjuvant treatment of brain metastases by targeting post-resection cavities. They obtained a 79% local control rate at 12 months, which compares favorably to historic whole brain radiation treatment results.
A volumetric study of CyberKnife hypofractionated stereotactic radiotherapy as salvage for progressive malignant brain tumors: initial experience. Giller et al. 2007. Researchers from Baylor University Medical Center used the CyberKnife System to perform fractionated stereotactic radiosurgery on lesions that are difficult to treat in a single fraction approach.
Survival following CyberKnife radiosurgery and hypofractionated radiotherapy for newly diagnosed glioblastoma multiforme. Lipani et al. 2008. Researchers from Stanford University performed CyberKnife System treatment on 20 GBM patients after tumor resection. The overall median survival was 16 months, which compares favorably to post-surgical external beam radiation therapy.
Cost-effectiveness analysis for trigeminal neuralgia: CyberKnife vs microvascular decompression. Tarricone et al. 2008. Investigators from Milan, Italy show that both radiosurgery using the non-invasive CyberKnife® System and a surgical treatment, microvascular decompression (MVD), produce high rates of pain relief. The costs of a hospital stay and surgery, however, make MVD more expensive than CyberKnife SRS.
CyberKnife radiosurgery for benign meningiomas: short-term results in 199 patients. Colombo et al. 2009. Researchers from Vicenza, Italy demonstrated a 5-year actuarial tumor control rate of 93.56% and a 0.5% complication rate. According to the authors, the ability to conveniently treat in multiple sessions allowed them to treat “63 patients (30%) who could not have been treated by single-session radiosurgical techniques.”
Quality of radiosurgery for single brain metastases with respect to treatment technology: a matched-pair analysis. Wowra et al. 2009. This study compares the technical features of the Gamma Knife and the CyberKnife® System, and their clinical outcomes in the treatment of single brain metastases, using the method of matched-pair analysis. Clinical outcomes were nearly identical between groups.
Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. Adler et al. 2009. Stanford researchers examined outcomes after radiosurgery using the CyberKnife® System for trigeminal neuralgia using treatment parameters that have evolved over several years. This “optimal” treatment approach resulted in pain relief judged as excellent or good by 96% of patients, with relatively low rates of facial numbness.
Early results of CyberKnife radiosurgery for arteriovenous malformations. Colombo et al. 2009. Researchers using the CyberKnife® System in Vicenza, Italy conducted a prospective study of 279 patients with arteriovenous malformations (AVMs) treated with the CyberKnife System. The overall rate of complete obliteration was 81.2% in patients with 36 months of follow-up, and no permanent complications were observed.
FOR MORE INFORMATION ON CYBERKNIFE TREATMENT YOU MAY PLEAS BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com.
Source: http://www.accuray.com/clinicans/clinical-development/applications/clinical-publications.aspx#Reviews
Intracranial:
Staged stereotactic irradiation for acoustic neuroma. Chang et al. 2005. Stanford researchers show that fractionated treatment using the CyberKnife System for acoustic neuromas may improve hearing preservation.
Robotically guided radiosurgery for children. Giller, et al. 2005. Researchers from Baylor University Medical Center used the CyberKnife System to achieve local control for children with some types of CNS tumors.
Visual field preservation after multisession CyberKnife radiosurgery for perioptic lesions. Adler, et al. 2006. Stanford University researchers used the CyberKnife System to obtain high rates of tumor control for tumors near (less than 2 mm from) the optic apparatus; over 90% of patients treated maintained or improved their vision.
Stereotactic radiosurgery using CT cisternography and non-isocentric planning for the treatment of trigeminal neuralgia. Lim et al. 2006. Researchers from Stanford University used the CyberKnife System to treat trigeminal neuralgia. Ninety percent of patients treated rated their pain control as excellent with limited facial numbness at 10 months follow-up.
Stereotactic radiosurgery of the postoperative resection cavity for brain metastases. Soltys, et al. 2007. Researchers from Stanford University used the CyberKnife System for adjuvant treatment of brain metastases by targeting post-resection cavities. They obtained a 79% local control rate at 12 months, which compares favorably to historic whole brain radiation treatment results.
A volumetric study of CyberKnife hypofractionated stereotactic radiotherapy as salvage for progressive malignant brain tumors: initial experience. Giller et al. 2007. Researchers from Baylor University Medical Center used the CyberKnife System to perform fractionated stereotactic radiosurgery on lesions that are difficult to treat in a single fraction approach.
Survival following CyberKnife radiosurgery and hypofractionated radiotherapy for newly diagnosed glioblastoma multiforme. Lipani et al. 2008. Researchers from Stanford University performed CyberKnife System treatment on 20 GBM patients after tumor resection. The overall median survival was 16 months, which compares favorably to post-surgical external beam radiation therapy.
Cost-effectiveness analysis for trigeminal neuralgia: CyberKnife vs microvascular decompression. Tarricone et al. 2008. Investigators from Milan, Italy show that both radiosurgery using the non-invasive CyberKnife® System and a surgical treatment, microvascular decompression (MVD), produce high rates of pain relief. The costs of a hospital stay and surgery, however, make MVD more expensive than CyberKnife SRS.
CyberKnife radiosurgery for benign meningiomas: short-term results in 199 patients. Colombo et al. 2009. Researchers from Vicenza, Italy demonstrated a 5-year actuarial tumor control rate of 93.56% and a 0.5% complication rate. According to the authors, the ability to conveniently treat in multiple sessions allowed them to treat “63 patients (30%) who could not have been treated by single-session radiosurgical techniques.”
Quality of radiosurgery for single brain metastases with respect to treatment technology: a matched-pair analysis. Wowra et al. 2009. This study compares the technical features of the Gamma Knife and the CyberKnife® System, and their clinical outcomes in the treatment of single brain metastases, using the method of matched-pair analysis. Clinical outcomes were nearly identical between groups.
Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. Adler et al. 2009. Stanford researchers examined outcomes after radiosurgery using the CyberKnife® System for trigeminal neuralgia using treatment parameters that have evolved over several years. This “optimal” treatment approach resulted in pain relief judged as excellent or good by 96% of patients, with relatively low rates of facial numbness.
Early results of CyberKnife radiosurgery for arteriovenous malformations. Colombo et al. 2009. Researchers using the CyberKnife® System in Vicenza, Italy conducted a prospective study of 279 patients with arteriovenous malformations (AVMs) treated with the CyberKnife System. The overall rate of complete obliteration was 81.2% in patients with 36 months of follow-up, and no permanent complications were observed.
FOR MORE INFORMATION ON CYBERKNIFE TREATMENT YOU MAY PLEAS BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com.
Wednesday, March 10, 2010
CYBERKNIFE & TRIGEMINAL NEURALGIA
FOR MORE INFORMATION YOU MAY PLEASE BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com
Monday, March 8, 2010
CYBERKNIFE RADIOSURGERY FOR HYPOTHALAMIC HAMARTOMAS
CYBERKNIFE RADIOSURGERY-TREATMENT OPTION FOR HYPOTHALAMIC HAMARTOMAS (A CASE PRESENTATION)
Dr.Sanjay Chandrasekhar, Dr.S.Balaji Subramanian, Dr.B.Subathira, Ms.S.Mahalakshmi
Department of Radiation Oncology, Apollo Specialty Hospital, Chennai.
INTRODUCTION:
Hypothalamic neuronal hamartoma is a rare congenital, non neoplastic heterotopia
variably associated with central precocious puberty and gelastic (laughing) seizures1,2,3,4 They are classified into sessile and pedunculated lesions depending on the width of their attachment to the tuber cinerium and pattern of growth which can be respectively contained inside the hypothalamic parenchyma or mainly expanding toward the ventricular or interpeduncular space4,5,6. Diagnosis is based on the characteristic location,
isointensity to normal brain, lack of contrast enhancement and absence of change in size
and morphology of the mass at follow up. Treatment options include medical management, surgery & radiosurgery.The main limitation of surgery lies in its inability
to completely resect intrahypothalamic lesions without causing neuro metabolic complications.Radiosurgery is an emerging modality to treat hypothalamic hamartomas, providing excellent seizure control7,8,9,10.Cyberknife radiosurgery technique does not require a stereotactic frame which may facilitate its use in children and young adults, offering a noninvasive option of treatment with lower complication rates.
CASE REPORT:
17 year old male patient was evaluated for intractable headache, vomiting &intermittent drop attacks of 2 months duration. Physical examination revealed bilateral papilloedema & diminution of vision in left eye with visual field defect of bitemporal hemianopia.
MR imaging of the brain showed a large suprasellar SOL with mass effect and hydrocephalus. After craniotomy, bilateral VP shunting was done. Biopsy from the vascular tumor showed neuronal cells in nests and loose aggregates separated and admixed with a fibrillary stroma. The cells ranged from normal appearing ganglion cells to more rounded cells with moderate to clear cytoplasm, small clusters of stromal calcification & areas of hemorrhage. IHC was positive for synaptophysin and neurofilament & negative for GFAP. These features were consistent with hypothalamic neuronal hamartoma. Considering the challenging neural and vascular anatomy surrounding the tumor, surgery was deferred in our patient and taken up for Cyberknife radiosurgery. Being the most accurate image guided procedure, providing submillimeter accuracy, Cyberknife allows treatment of the entire lesion as visible on neuroimaging studies including hypothalamic components. A total dose of 27.5Gy was delivered in 5 fractions to the tumor. A dose of 5.5Gy was prescribed to the 80 % isodose line covering 93% of the target volume. The entire treatment was done as outpatient and the patient tolerated the treatment well.
RESULT:
Follow up MRI done at 8 months revealed minimal regression in the size and vascularity of the tumor. Patient had a good clinical response as evidenced by seizure free interval of about 8 months post radiosurgery .There were no neurological complications post-treatment.
CONCLUSION:
Cyberknife radiosurgery is a safe and effective treatment for hypothalamic hamartomas. Radiosurgery provides substantial seizure improvement. Distinct from other surgical treatments, it is non invasive and virtually free of major complications.
PURPOSE OF PRESENTATION:
This case is being presented for its rarity and also to share our experience of treating hypothalamic hamartoma using Cyberknife radiosurgery for the first time in India. In concordance with other reports11,12, Cyberknife Radiosurgery appears to be an effective local treatment option with early clinical outcome and decreased morbidity.
COMPETING INTERESTS:
The author(s) declare that they have no competing interests.
ACKNOWLEDGEMENTS:
The authors would like to place on record the involvement of Dr.B.Chidambaram, Paediatric Neurosurgeon, Childs Trust Hospital, Chennai in the discussions regarding this case and for his academic inputs.
Dr.Sanjay Chandrasekhar, Dr.S.Balaji Subramanian, Dr.B.Subathira, Ms.S.Mahalakshmi
Department of Radiation Oncology, Apollo Specialty Hospital, Chennai.
INTRODUCTION:
Hypothalamic neuronal hamartoma is a rare congenital, non neoplastic heterotopia
variably associated with central precocious puberty and gelastic (laughing) seizures1,2,3,4 They are classified into sessile and pedunculated lesions depending on the width of their attachment to the tuber cinerium and pattern of growth which can be respectively contained inside the hypothalamic parenchyma or mainly expanding toward the ventricular or interpeduncular space4,5,6. Diagnosis is based on the characteristic location,
isointensity to normal brain, lack of contrast enhancement and absence of change in size
and morphology of the mass at follow up. Treatment options include medical management, surgery & radiosurgery.The main limitation of surgery lies in its inability
to completely resect intrahypothalamic lesions without causing neuro metabolic complications.Radiosurgery is an emerging modality to treat hypothalamic hamartomas, providing excellent seizure control7,8,9,10.Cyberknife radiosurgery technique does not require a stereotactic frame which may facilitate its use in children and young adults, offering a noninvasive option of treatment with lower complication rates.
CASE REPORT:
17 year old male patient was evaluated for intractable headache, vomiting &intermittent drop attacks of 2 months duration. Physical examination revealed bilateral papilloedema & diminution of vision in left eye with visual field defect of bitemporal hemianopia.
MR imaging of the brain showed a large suprasellar SOL with mass effect and hydrocephalus. After craniotomy, bilateral VP shunting was done. Biopsy from the vascular tumor showed neuronal cells in nests and loose aggregates separated and admixed with a fibrillary stroma. The cells ranged from normal appearing ganglion cells to more rounded cells with moderate to clear cytoplasm, small clusters of stromal calcification & areas of hemorrhage. IHC was positive for synaptophysin and neurofilament & negative for GFAP. These features were consistent with hypothalamic neuronal hamartoma. Considering the challenging neural and vascular anatomy surrounding the tumor, surgery was deferred in our patient and taken up for Cyberknife radiosurgery. Being the most accurate image guided procedure, providing submillimeter accuracy, Cyberknife allows treatment of the entire lesion as visible on neuroimaging studies including hypothalamic components. A total dose of 27.5Gy was delivered in 5 fractions to the tumor. A dose of 5.5Gy was prescribed to the 80 % isodose line covering 93% of the target volume. The entire treatment was done as outpatient and the patient tolerated the treatment well.
RESULT:
Follow up MRI done at 8 months revealed minimal regression in the size and vascularity of the tumor. Patient had a good clinical response as evidenced by seizure free interval of about 8 months post radiosurgery .There were no neurological complications post-treatment.
CONCLUSION:
Cyberknife radiosurgery is a safe and effective treatment for hypothalamic hamartomas. Radiosurgery provides substantial seizure improvement. Distinct from other surgical treatments, it is non invasive and virtually free of major complications.
PURPOSE OF PRESENTATION:
This case is being presented for its rarity and also to share our experience of treating hypothalamic hamartoma using Cyberknife radiosurgery for the first time in India. In concordance with other reports11,12, Cyberknife Radiosurgery appears to be an effective local treatment option with early clinical outcome and decreased morbidity.
COMPETING INTERESTS:
The author(s) declare that they have no competing interests.
ACKNOWLEDGEMENTS:
The authors would like to place on record the involvement of Dr.B.Chidambaram, Paediatric Neurosurgeon, Childs Trust Hospital, Chennai in the discussions regarding this case and for his academic inputs.
Tuesday, February 16, 2010
PET CT WITH T-O-F TECHNOLOGY AND CYBERKNIFE ROBOTIC RADIOSURGERY
FIRST TIME IN INDIA - CYBERKNIFE ROBOTIC RADIO SURGERY SYSTEM AND PET CT WITH T-O-F TECHNOLOGY AT APOLLO SPECIALITY HOSPITAL.
GREAT DIAGNOSTIC AND TREATMENT FACILITY NOW AT APOLLO SPECIALITY HOSPITAL
Apollo Speciality Hospitals, Teynampet, Chennai has installed the latest state-of art Positron Emission Tomography system. The advanced 64 slice PET-CT system with time-of-flight technology is the first and the only one of its kind installed in India is known to provide for increased patient comfort and access, delivers unprecedented high quality imaging leading to better diagnosis for patients for Cancer, Cardiology and Neurology complications.
Speaking on the occasion, Dr. Cornelis A Hoefnagel, MD, Ph.D, a leading Consultant, eminent speaker, in Nuclear Medicine and a pioneer in PET-CT imaging from the Netherlands Cancer Institute, Amsterdam said, “The Hybrid imaging with the PET -CT, matching function with anatomy provides the greatest accuracy and newer insights in Oncology, Cardiology and Neurology and Infection.
The Advantages
It enables lower radiation dose as a result it lowers cost significantly.
It reduces imaging time which benefits scan time and increased throughput.
It offers excellent image quality increasing diagnostic confidence`
FOR MORE INFORMATION ON PET CT YOU MAY PLEASE BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com
GREAT DIAGNOSTIC AND TREATMENT FACILITY NOW AT APOLLO SPECIALITY HOSPITAL
Apollo Speciality Hospitals, Teynampet, Chennai has installed the latest state-of art Positron Emission Tomography system. The advanced 64 slice PET-CT system with time-of-flight technology is the first and the only one of its kind installed in India is known to provide for increased patient comfort and access, delivers unprecedented high quality imaging leading to better diagnosis for patients for Cancer, Cardiology and Neurology complications.
Speaking on the occasion, Dr. Cornelis A Hoefnagel, MD, Ph.D, a leading Consultant, eminent speaker, in Nuclear Medicine and a pioneer in PET-CT imaging from the Netherlands Cancer Institute, Amsterdam said, “The Hybrid imaging with the PET -CT, matching function with anatomy provides the greatest accuracy and newer insights in Oncology, Cardiology and Neurology and Infection.
The Advantages
It enables lower radiation dose as a result it lowers cost significantly.
It reduces imaging time which benefits scan time and increased throughput.
It offers excellent image quality increasing diagnostic confidence`
FOR MORE INFORMATION ON PET CT YOU MAY PLEASE BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com
Wednesday, January 20, 2010
Rationale and Potential Clinical Applications for CyberKnife Robotic IMRT™
The CyberKnife® System as an Image-guided Intensity Modulated Radiotherapy Device: Rationale and Potential Clinical Applications for CyberKnife Robotic IMRT™
Donald B. Fuller, M.D., Radiation Oncologist Radiosurgery Medical Group (RSMG); CyberKnife Centers of San Diego
In clinical practice, the CyberKnife® Robotic Radiosurgery System has been almost exclusively used as a radiosurgical device, engineered to deliver conformal, ablative radiation treatments in one to five fractions to a wide variety of malignant lesions in the CNS, head and neck, lung, liver, pancreas, prostate and other sites.1-8 Although there is no medical reason why this device has not been used to deliver conventionally fractionated radiotherapy, this function has not previously been described, presumably due to the long treatment times associated with early-generation CyberKnife Systems. Nevertheless, the MultiPlan® Treatment Planning System is capable of computing very elegant intensity modulated radiotherapy (IMRT) dose distributions, and improvements in device efficiency have made the delivery of these IMRT plans feasible in clinical practice, thus leading to new CyberKnife treatment applications that would best be described as “Robotic IMRT™.”
The new CyberKnife VSI™ platform includes a number of enhancements that improve efficiency, including Sequential Optimization treatment planning, the Iris™ Variable Aperture Collimator (which allows for modulation of the beam during treatment9,15), the increased dose rate of a 1,000 MU/min linear accelerator and a 20% increase in robotic traversal speed. In addition, a treatment time reduction tool accessed during plan optimization allows the user to reduce the total number of treatment beams and nodes while still meeting treatment plan objectives.
Collectively, these enhancements create a device that can reduce treatment times by over half compared with predecessor CyberKnife Systems, while maintaining the precision and accuracy of the CyberKnife product.
LIVER METASTASES TREATMENT
Stereotactic body radiation therapy for liver metastases
O Dawood, A Mahadevan, K Goodman ,European J Cancer 2009;45:2947-2959.
This review focuses on stereotactic body radiation therapy (SBRT) as an alternative, non-invasive approach to the treatment of liver metastases. Treatment considerations of SBRT for liver metastases are presented with particular emphasis on the challenges of organ motion and the low tolerance of the surrounding hepatic parenchyma. Multiple approaches to tumor motion are discussed, including tumor tracking versus motion-compensation techniques. Issues of patient eligibility criteria, patient set-up, target definition, treatment dosimetry and fractionation are also discussed. Clinical results to date from 15 published reports, including a summary of the latest in-press results from Stanford using the CyberKnife System, are presented. These clinical reports demonstrate the safety and efficacy of SBRT for liver metastasis with 18-month and 2-year local control rates ranging from 71-93% and 71-86%, respectively.
The review concludes by stressing the importance of addressing hepatic tumor motion to ensure the dose reaches the tumor and spares the surrounding normal tissue. The authors suggest more rigorous phase II clinical studies are necessary to establish the long-term durability of efficacy and toxicity results.
SOURCE : FOCUS NEWSLETTER - JAN 2010
O Dawood, A Mahadevan, K Goodman ,European J Cancer 2009;45:2947-2959.
This review focuses on stereotactic body radiation therapy (SBRT) as an alternative, non-invasive approach to the treatment of liver metastases. Treatment considerations of SBRT for liver metastases are presented with particular emphasis on the challenges of organ motion and the low tolerance of the surrounding hepatic parenchyma. Multiple approaches to tumor motion are discussed, including tumor tracking versus motion-compensation techniques. Issues of patient eligibility criteria, patient set-up, target definition, treatment dosimetry and fractionation are also discussed. Clinical results to date from 15 published reports, including a summary of the latest in-press results from Stanford using the CyberKnife System, are presented. These clinical reports demonstrate the safety and efficacy of SBRT for liver metastasis with 18-month and 2-year local control rates ranging from 71-93% and 71-86%, respectively.
The review concludes by stressing the importance of addressing hepatic tumor motion to ensure the dose reaches the tumor and spares the surrounding normal tissue. The authors suggest more rigorous phase II clinical studies are necessary to establish the long-term durability of efficacy and toxicity results.
SOURCE : FOCUS NEWSLETTER - JAN 2010
Tuesday, January 5, 2010
CYBERKNIFE FOR GASTRIC CANCERS
Stereotactic body radiotherapy for isolated para-aortic lymph node recurrence after curative resection in gastric cancer
Metastases from gastric cancer are common and can progress rapidly; even with aggressive treatment 5-year survival rates are low. However, researchers from Korea Institute of Radiological & Medical Sciences hypothesized that there is a certain population of such patients in whom the disease follows a more indolent course, based on studies of patients with
resected liver metastases. This population may benefit from SRS of isolated metastases from
gastric primaries. Thus, they treated 7 such patients with the CyberKnife® System, delivering 45 to 51 Gy (median 48 Gy) in 3 fractions. The patients were followed for 14 to 33 months (median 26 months). Local control was achieved in 6 of 7 patients; 2 patients were disease-free, 3 were alive with disease, and 2 patients died of disease progression. Three-year actuarial overall survival was 43%, and disease-free survival was 29%. The authors conclude that the results support their hypothesis that an indolent subgroup with less aggressive disease progression who could benefit
from the use of local treatments such as CyberKnife Radiosurgery.
Source: Accuray's focus newsletter
Metastases from gastric cancer are common and can progress rapidly; even with aggressive treatment 5-year survival rates are low. However, researchers from Korea Institute of Radiological & Medical Sciences hypothesized that there is a certain population of such patients in whom the disease follows a more indolent course, based on studies of patients with
resected liver metastases. This population may benefit from SRS of isolated metastases from
gastric primaries. Thus, they treated 7 such patients with the CyberKnife® System, delivering 45 to 51 Gy (median 48 Gy) in 3 fractions. The patients were followed for 14 to 33 months (median 26 months). Local control was achieved in 6 of 7 patients; 2 patients were disease-free, 3 were alive with disease, and 2 patients died of disease progression. Three-year actuarial overall survival was 43%, and disease-free survival was 29%. The authors conclude that the results support their hypothesis that an indolent subgroup with less aggressive disease progression who could benefit
from the use of local treatments such as CyberKnife Radiosurgery.
Source: Accuray's focus newsletter
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