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®

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.

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.

CYBERKNIFE & TRIGEMINAL NEURALGIA

FOR MORE INFORMATION YOU MAY PLEASE BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com

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.