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
Sunday, October 10, 2010
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
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