Friday, January 29, 2016

CyberKnife therapy of 24 multiple brain metastases from lung cancer

CyberKnife therapy of 24 multiple brain metastases from lung cancer

Brain metastases from systemic cancer are the most common type of intracranial neoplasm in adults, being almost 10 times more common than primary malignant brain tumors, which cause a significant burden on the management of patients with advanced cancer (). The lungs represent one of the most frequent sources of metastases to the brain, with a probability of (36–64%) (). Symptoms suffered by the patients include headaches, epilepsy, focal weakness, numbness or changes in mental status. The prognosis of patients with brain metastases is not optimistic and the median survival time is ∼1–2 months if left untreated. The 1-year survival rate has been recorded as 10.4% (,). The treatment of metastatic brain tumors is complex; not only due to being able to provide local control and improve neurological function, but also due to factors such as age, performance and systemic disease status and the size, volume, location and number of metastases at presentation

CyberKnife is a robotic radiosurgery system with a linear particle accelerator (linac), which is coupled with real-time imaging to track and compensate for the patient’s or target’s motion. As a relatively non-invasive treatment modality, CyberKnife demonstrates certain benefits, including a more accurate target localization and improved dose delivery for the management of metastatic brain tumors that allows higher biologically effective dose delivery without increased incidence of toxicity.

In the present case, the results for the treatment of multiple brain metastases after CyberKnife surgery with a 7–8 Gy marginal dose was promising. CyberKnife for metastatic brain tumors is an effective and safe method for reducing the marginal dose prescribed for multiple brain metastases and for minimizing the radiation-related neurotoxicities. In conclusion, CyberKnife, a focused, highly-targeted radiosurgery and fractionated radiotherapy is particularly useful for multiple brain metastases. CyberKnife provides the advantage of the management of local recurrence and a tolerable complication rate. Although the treatment of brain metastases has been performed with CyberKnife, the clinical significance and optimal dose fractionation scheme require further investigation.

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A 60-year-old female with a history of Stage IV ovarian carcinoma presented with rising CA-125 levels (21.1 U/ml to 34.4 U/ml), signifying a probable ovarian carcinoma recurrence. Subsequent MRI showed a 2.8 x 2.5 cm nodule in the region of the left upper vaginal cuff which was confirmed by bimanual examination. Initial diagnosis of Stage IV ovarian carcinoma was made six years earlier when the patient presented with right-sided pleural effusion and CA-125 of 1482 U/ml. An exploratory laparotomy was done and an omental cake, peritoneal studding and a nodule adjacent to the rectosigmoid were resected. Pathology showed poorly differentiated serous papillary ovarian carcinoma.

Over the next four years the patient underwent multiple rounds of chemotherapy as well as stem cell transplant and additional surgical resection in the effort to control her disease. The patient’s latest chemotherapy was prematurely discontinued when she experienced a severe anaphylactoid reaction. At that time the decision was made to follow her closely with imaging and CA-125 measurements.

CyberKnife® Treatment Rationale

 Epithelial ovarian cancer is the leading cause of death among women. More than 70% of women with epithelial ovarian cancer have Stage III or IV disease at the time of diagnosis
1 Adjuvant chemotherapy is recommended for all patients with advanced stage ovarian cancer after appropriate surgery. However, more than 70% of patients relapse, with a median time to progression of less than 2 years.
2 Secondary surgery for recurrent patients has not significantly improved survival. Radiation therapy has improved survival in a subset of patients with chemotherapy-refractory disease, particularly those patients with minimal residual or relapsed disease to the pelvis, and has provided good palliation in patients with local abdominopelvic symptoms.
3 This patient presented with a recurrent ovarian cancer in the left vaginal cuff. Due to the patient’s medical history, she was not a candidate for further chemotherapy or surgery. Nevertheless, the left vaginal cuff recurrence was and had always been the only site of recurrence in this patient, therefore aggressive definitive care was indicated.
The use of stereotactic body radiotherapy as an alternative to brachytherapy for gynecologic tumors has been reported to achieve excellent local control rates with minimal toxicities.

4 offered a minimally invasive method for delivering hypofractionated radiation to the left vaginal cuff of a patient who had failed two surgical resections and numerous cycles of chemotherapy.

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Wednesday, January 20, 2016

CyberKnife - Hemicranial Meningioma

Successful CyberKnife Irradiation of 1000 cc Hemicranial Meningioma: 6-year Follow-up

Meningiomas are common benign tumors with accepted treatment approaches and usually don't challenge healthcare specialists. We present a case of a huge unresectable hemicranial meningioma, which was successfully treated with hypofractionated irradiation.

A male patient, sixty-two years of age, suffered for over 12 years from headaches, facial deformity, right eye displacement, right eye movement restriction, right-sided ptosis, and facial hypoesthesia. MRI and CT studies revealed an extended hemicranial meningioma. Prior to irradiation, the patient underwent four operations. Eventually, the tumor was irradiated with the CyberKnife in August 2009. Tumor volume composed 1085 cc. The mean dose of 35.3 Gy was delivered in 7 fractions (31.5 Gy at 72% isodose line comprising 95% of tumor volume). The patient was followed during six years and experienced only mild (Grade 1-2 CTCAE) acute skin and mucosa reactions. During the follow-up period, we observed target volume shrinkage for 17% (for 26% after excluding hyperostosis) and regression of intracranial hypertension signs.

Due to the extreme volume and complex shape of the tumor, spreading along the surface of the hemisphere as well as an optic nerve involvement, the case presented would not be generally considered suitable for irradiation, especially for hypofractionation. 

We regard this clinical situation not as a treatment recommendation, but as a demonstration of the underestimated possibilities of hypofractionation regimen and CyberKnife system, both of which are limited with our habit of conventional treatments.

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Monday, December 21, 2015


In many patients with brain metastases, the primary therapeutic aim is symptom palliation and maintenance of neurologic function, but in a subgroup, long-term survival is possible. Local control in the brain, and absent or controlled extracranial sites of disease are prerequisites for favorable survival. 

Stereotactic radiosurgery (SRS) is a focal, highly precise treatment option with a long track record. Its clinical development and implementation by several pioneering institutions eventually rendered possible cooperative group randomized trials. A systematic review of those studies and other landmark studies was undertaken. 

Most clinicians are aware of the potential benefits of SRS such as a short treatment time, a high probability of treated-lesion control and, when adhering to typical dose/volume recommendations, a low normal tissue complication probability. 

However, SRS as sole first-line treatment carries a risk of failure in non-treated brain regions, which has resulted in controversy around when to add whole-brain radiotherapy (WBRT). SRS might also be prescribed as salvage treatment in patients relapsing despite previous SRS and/or WBRT. An optimal balance between intracranial control and side effects requires continued research efforts.

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Klatskin tumour

A fifty-four years old Marwari patient from Assam presented with progressive jaundice and intermittent episodes of abdominal pain for three months. CT scan of abdomen showed a small (1.5 x 1.5 cm) mass in the bifurcation of common bile duct which is causing biliary tract obstruction and hence jaundice. Portal nodes were not enlarged and there was no lesion in the liver parenchyma. At presentation, serum bilirubin level was high (14.7 mg/dl). Endoscopic biopsy and brushing cytology was adenocarcinoma and clinic-radiological diagnosis was ‘Klatskin tumour’. 

Metallic stenting was done to relieve jaundice and after stenting serum bilirubin level came down rapidly. PET scan showed increased uptake in the biliary duct region mass without any sign of metastasis. He was evaluated and planned for treatment with robotic radiosurgery. He was treated using robotic radiosurgery (CyberKnife) with high precision radiotherapy technique after fiducial placement (gold seeds) near the tumour. After one year, the patient had no obvious complain, liver function (no jaundice) was normal and CT scan evaluation showed completed resolution of the mass.  

Klatskin tumour is an uncommon tumour that arises from the bifurcation of common bile duct in the abdomen (duct that drains bile from liver). Patients usually present with progressive (increasing) persistent jaundice followed by pain in the upper abdomen. Surgical excision is the mainstay of treatment. However, surgery is not possible in majority of the patients owing to the location of the tumour, high jaundice and medical condition. Chemotherapy may not be an optimal option in majority of the patients as they present with high jaundice. Majority of such patients with poor medical condition are treated with only supportive care and prognosis is dismal (survival for a few months only).

Patients with metallic stent have relief from jaundice but unfortunately in a few weeks time, the stent gets blocked with tumour growth. Patients again present with high jaundice and have severely impaired quality of life. They complain of severe itching of entire body, loss of appetite and succumb due to impaired liver function from high jaundice/obstruction. The treatment is to have a longer ‘jaundice-free period’ which in turn improves quality of life and possibly survival function as well.  

Stereotactic body radiation therapy’s high dose radiation ‘sterilizes’ the metallic stent and bile duct region. It is assumed that with radiation therapy, blockage of bile duct and stent is delayed and patients have longer jaundice-free period.In Klatskin tumour, CyberKnife allows to deliver high dose of radiation in a short duration to the target without significant morbidity. 

Article by Dr.Debnarayan Dutta

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