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.
Monday, March 8, 2010
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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