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.

Source : Scoop it

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CYBERKNIFE TREATMENT FOR TRIGEMINAL NEURALGIA

tA 68 year old gentleman from Kolkata presented to our outpatient facility with complaints of left sided facial pain. He has been on medications for trigeminal neuralgia for the past 24 years with little benefit. He had been on and off medications and had also tried alternative medicine. He was not willing to undergo surgery. He was referred here for radiosurgery. He was irradiated with single fraction radiosurgery by cyberknife in July 2013. Less than two months later has 90% relief of pain.

Trigeminal neuralgia is a condition where the patients experience unbearable pain on one side of the face with major debilitation due to pain. These patients are treated with cyberknife radiosurgery so that a large dose is delivered to 2mm  of the nerve with extreme precision. The adjacent brainstem can be successfully protected with cyberknife radiosurgery and the pain relief starts within a month. 

The patient was under treatment with Dr.Rathna Devi, senior consultant Radiation Oncologist. 

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Radiosurgery in gastro-intestinal malignancies

Radiosurgery in gastro-intestinal malignancies 

DR.DEBNARAYAN DUTTA, Radaitaion oncologist, Apollo speciality Hospital

Common gastro-intestinal (GI) malignancies are colon cancer, carcinoma rectum and anal canal, pancreatic cancer, cholangiocarcinoma, carcinoma stomach, hepatocellular carcinoma (HCC) and liver metastasis. Other uncommon tumours include gastro-intestinal stromal tumour (GIST), klaskin tumour and neuro-endocrine tumour. Surgery is the treatment option in these tumours. Unfortunately, majority of these tumours are inoperable at presentation and treated with supportive/palliative intent. Majority of these tumours are relatively chemotherapy (CT) resistant. Role of conventional radiation therapy (RT) in gastro-intestinal malignancies are also not well defined in many of these tumours.

Response rate with delivered dose is not acceptable, and dose escalation is not possible with conventional RT without compromising in critical structure (small intestine, duodenum) tolerance. With modern stereotactic whole body RT (SBRT) higher dose of radiation can be delivered in shorter duration and normal tissue tolerance is respected. SBRT has evolved in recent years and also have promise to improve local control in these relative resistant tumours. Pre-operative and adjuvant RT is established in carcinoma of rectum.

In recent years, short course RT (hypofractionated RT, 25 Gy/5 Fr) had shown to be equally effective as conventional RT (1.8-2 Gy/Fr) in inoperable rectal cancer. Role of conventional RT in inoperable pancreatic cancer has been argued in the EORTC study. Whereas, short course RT (fractionated radiosurgery) is slowly being accepted as an option to complete RT early, start adjuvant CT at the earliest and also improve quality of life (QOL). In liver metastasis, radiosurgery is a non-invasive alternative to surgery. Higher equivalent radiation dose delivered with radiosurgery there may have comparable survival function in selected patients.

Radiosurgery is an option in liver tumour close to porta, sub-diaphragmatic location (segment VIII), nodal involvement and in medically inoperable patients. In hepatocellular carcinoma (HCC), fractionated radiosurgery is an option as ‘bridge therapy’ for patients waiting for liver transplant, medically inoperable patients, chemotherapy resistant, post TACE residual and in recurrent HCCs. Radiosurgery is also consider as primary treatment in suitable patients. There is an ongoing multicentric randomized trial comparing chemotherapy and radiosurgery in HCCs.

In uncommon slow growing tumours such as cholangiocarcinoma, neuro-endocrine tumour and klaskin tumour fractionated radiosurgery have excellent response rate and improve symptoms. In conclusion, modern fractionated stereotactic radiosurgery is an option in many of the GI malignancies improves response rate and also may improve QOL. In coming years with publication of more matured data from randomized and prospective phase II studies the role of radiosurgery will be established. ours , 2) require only thermoplastic mask, no need for invasive frame, 3) has inverse planning system, can spare critical structure, 4) there is a ‘intra-fraction’ correction technology with imaging, 5) there is no need to change the source, hence may be more cost effective and 6) can be used to treat extra-cranial tumours also. CyberKnife has a linear accelerator attached with a robot and is capable of treatment from various coplanar and non-coplanar field arrangements. CyberKnife has sub-millimeter accuracy and unmatched dose distribution. 

The advanced technology behind CyberKnife uses image guidance technology and computer-controlled robotics to deliver and extremely precise dose of radiation to targets, avoiding the surrounding healthy tissue, and adjusting for patient and tumor movement during treatment. In conclusion, CyberKnife is an extension of gammaknife radiosurgery delivery system. This machine has immense promise to treat with short course regimens with high dose and improve local control without increasing toxicities.

Radiosurgery in brain tumours

Radiosurgery in brain tumours Dr.DEBNARAYAN DUTTA, CONSULTANT RADIATION ONCOLOGIST< APOLLO SPECIALITY HOSPITAL CHENNAI

Short course radiation therapy is the one of the most talked about subject in recent years and also a fascinating research zone. Hypofractionated radiation therapy is an old concept, but only in recent years with tremendous improvement in radiation therapy delivery technologies there is a significant visible surge in it’s applicability in clinical practice. Modern radiation therapy technology is capable of delivering high dose to the target while sparing majority of the adjacent critical structures. Hence, it is possible to deliver short course of treatment regimen with higher dose per fraction without increasing in toxicity. In brain tumours, radiosurgery with gamma-knife is considered standard of care in many of the clinical indications such as small meningiomas, acaustic schwannomas, residual low grade gliomas, AVMs and solitary/ oligo brain metastasis. Gamma-knife radiosurgery is in clinical practice for more than five decades.  There are several prospective and randomized studies (level I evidence) with long-term follow up data supporting the use of radiosurgery in these clinical indications. Other indications of radiosurgery are pituitary tumour, craniopharyngiomas, glomus tumours, chordomas and others. Robotic radiosurgery (CyberKnife®) is precision radiosurgery delivery system and an extension of gamma-knife system. CyberKnife uses the principle of gamma-knife, but with linear accelerator source instead of multiple cobalt sources. CyberKnife is capable to treating all tumours indicated for gamma-knife with similar accuracy. This modern tool has some additional advantages from gamma-knife, such as 1) CyberKnife can use fractionated treatment, hence relatively larger tumours can be treated, 2) require only thermoplastic mask, no need for invasive frame, 3) has inverse planning system, can spare critical structure, 4) there is a ‘intra-fraction’ correction technology with imaging, 5) there is no need to change the source, hence may be more cost effective and 6) can be used to treat extra-cranial tumours also. CyberKnife has a linear accelerator attached with a robot and is capable of treatment from various coplanar and non-coplanar field arrangements. CyberKnife has sub-millimeter accuracy and unmatched dose distribution.  The advanced technology behind CyberKnife uses image guidance technology and computer-controlled robotics to deliver and extremely precise dose of radiation to targets, avoiding the surrounding healthy tissue, and adjusting for patient and tumor movement during treatment. In conclusion, CyberKnife is an extension of gammaknife radiosurgery delivery system. This machine has immense promise to treat with short course regimens with high dose and improve local control without increasing toxicities. FOR more information you may please blog your comments or write to lakshmipriya_b@apollohospitals.com

CYBERKNIFE TREATMENT FOR ACOUSTIC NEUROMAS

CYBERKNIFE TREATMENT FOR ACOUSTIC NEUROMAS

An acoustic Neuroma, sometimes classified as vestibular schwannoma, is a noncancerous tumor which greatly affects the vestibulocochlear cranial nerve. This nerve is responsible for your perception of hearing and stability.

One treatment solution is cyberknife treatment . The reason for this treatment technique is to eliminate the tumor, particularly if it is already large enough to result in total deafness. Furthermore, a significant tumor can also affect and alter the capabilities of other regional organs.

The appearance of cyberknife approach is a less intrusive method for treatment is Cyberknife VSI’s noninvasive surgery for acoustic neuroma. This treatment procedure utilizes gamma radiation to eradicate the developing tumor and leave the site totally free of possibly damaging tumor cells. This type of intervention not simply guards healthy tissues, but produces minimal side effects, and boosts comfort for the patient when focusing on the cancer cells in a precise manner.

With cyberknife VSI’s noninvasive surgery for acoustic neuroma today, the apollo speciality hospital, chennai, India uses up-to-date research, technologically advanced technologies, and has professional physicians to deliver this revolutionary cyberknife treatment method for effective treatment of the acoustic neuroma.

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CYBERKNIFE IN TREATMENT OF VARIOUS CANCERS

Precision without Incision
One of the UK’s most senior Clinical Oncologists is St Bartholomew's Dr Nick Plowman and he heads this section. In his article 'CyberKnife® – cancer search and destroy’ he explains the use of this powerful new treatment option as both a stand-alone method and in collaboration with other treatments such as chemotherapy.

Then Dr Andrew Gaya, Consultant Clinical Oncologist at Guy’s & St Thomas’ Hospitals NHS Foundation Trust, explains: “Most advances in cancer treatment are small steps forward, but occasionally there is a giant leap.”

CyberKnife® has provided this leap and is now a viable alternative treatment option for:

•Major operations such as lung and liver resections,
•Removal of pancreas and prostatectomy
•Tumours in the body
•Tumours in the brain and spine including brain metastases, primary brain or brainstem tumours, pituitary tumours, acoustic neuromas, meningiomas, arteriovenous malformations and trigeminal neuralgia.

Source : http://www.totalhealth.co.uk/your-condition/cyberknife%C2%AE

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Cyberknife Radiation Successful For Treating Tigeminal Neuralgia

Cyberknife Radiation Successful For Treating Tigeminal Neuralgia
A small study published online in the Journal of NeuroInterventional Surgery shows that a technique in which highly concentrated beams of radiation are used, known as Cyberknife, can relieve the stabbing pain of the facial nerve condition trigeminal neuralgia.
For their study, the researchers treated 17 patients with trigeminal neuralgia between the ages of 36 and 90, with Cyberknife radio surgery between 2007 and 2009. All patients had suffered between 1 and 11 years from the condition and failed to respond to common methods of treatment.

The treatment consisted of zapping a maximum radiation dose of 73.06 Gy into a 6mm length of the trigeminal nerve, just 2 to 3mm from the root, after which the patients were frequently monitored for an average period of just less than 12 months.

Whist 14 patients reported either a partial or complete relief of symptoms; complete data was available for 16 patients. The average time before the symptoms were relieved was slightly less than two months, with variations from three weeks to half a year. The researchers noted a relapse after the procedure in four patients, occurring between 3 and 18 months later.

None of the patients reported any major complications as a result of the procedure, with only two patients reporting any sensory side effects. The researchers conclude that radio surgery provides a viable alternative to more invasive approaches and should be further investigated.

Written by Petra Rattue
Copyright: Medical News Today
Source: http://www.medicalnewstoday.com/articles/240938.php

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INDICATIONS FOR CYBERKNIFE TREATMENT

The indications for which cyberknife treatment could be useful is indicated below : Dr.Rathna devi, Senior consultant, Radiation oncology
Intra Cranial Tumours – Indications

• Skull base Tumours
• Meningiomas
• Brain Metastases
• Acoustic Schwannoma
• AVM
• Pituitary adenoma
• Low/Hi grade Glioma
Boost Re- irradiation
• Functional
• Trigeminal Neuralgia
• Spinal Tumors - Primary
Re irradiation - Metastases
• Craniophrangioma
• Chordoma
• Hamartoma
• Harmangio blastoma
• Glomus Jugular Tumor
• Boost for Nasopharynx carcinoma

EXTRA CRANIAL SITES – INDICATIONS
. Lung - Primary
- Metastases
• Liver - Primary
- Metastases
• Head & Neck - Tonsil
(Re Irradiation) - Larynx
- Pharynx
- Lacrimal Gland

• Sino Nasal Carcinoma - Boost
- Re –irradiation
• Carcinoma Pancreas
• Carcinoma Gall Bladder
• Para arotic lymph nodes
• Melanoma
• Carcinoma prostate
• Recurrent Orbital Tumours Renal Tumours
• Soft tissue sarcoma


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Stereotactic body radiotherapy for low-risk prostrate cancer

Stereotactic body radiotherapy for
low-risk prostate cancer:
five-year outcomes
Debra E. Freeman1 and Christopher R. King2
1 Naples Radiation Oncology, PA, USA
2 Department of Radiation Oncology, UCLA School of Medicine, CA, USA
Radiation Oncology 2011, 6:3doi:10.1186/1748-717X-6-3
Purpose
Hypofractionated, stereotactic body radiotherapy (SBRT) is an emerging treatment approach for prostate cancer. We present the outcomes for low-risk prostate cancer patients with a median follow-up of 5 years after SBRT.
Method and Materials
Between Dec. 2003 and Dec. 2005, a pooled cohort of 41 consecutive patients from Stanford, CA and Naples, FL received SBRT with CyberKnife for clinically localized, low-risk prostate cancer. Prescribed dose was 35-36.25 Gy in five fractions. No patient received hormone therapy. Kaplan-Meier biochemical progression-free survival (defined using the Phoenix method) and RTOG toxicity outcomes were assessed.
Results
At a median follow-up of 5 years, the biochemical progression-free survival was 93% (95% CI = 84.7% to 100%). Acute side effects resolved within 1-3 months of treatment completion. There were no grade 4 toxicities. No late grade 3 rectal toxicity occurred, and only one late grade 3 genitourinary toxicity occurred following repeated
urologic instrumentation.
Conclusion
Five-year results of SBRT for localized prostate cancer demonstrate the efficacy and safety of shorter courses of high dose per fraction radiation delivered with SBRT technique. Ongoing clinical trials are underway to further explore this treatment approach.

Source: www.accuray.com

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CYBERKNIFE & TRIGEMINAL NEURALGIA

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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.

SOURCE: ACCURAY FOCUS NEWSLETTER JAN, 2010

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

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

PROGRESS IN RADIATION ONCOLOGY

PROGRESS IN RADIATION ONCOLOGY

Dr. Janos Stumpf - ADVISOR ONCOLOGY – CYBERKNIFE SERVICES

End of the month November, was an academic feast for the Indian Radiation Oncologists at Hyderabad.

The content of the conference can be summarized in three words: It was about Research, Discipline and Development, especially that of the new machines. It is our pride to realize and say that even latest knowledge about the technical progress has found its way to India, no matter how expensive the machines are. “Precision in Delivery of Radiation” is the mantra for all these technical aspects. Tomotherapy, Cyberknife and Rapid Arc are all the ways to do radio therapy on an extremely precise way.

Cyberknife was covered by two speakers. An eminent guest from California Dr.Nissar Syed was kind enough to give an over-all review about the machine. His talk was followed by the ‘Indian experience’ with Cyberknife based on more than hundred fifty cases treated already at ASH Chennai. Characteristics of the first 150 cases were presented. Apollo has considerable success:- partial remission even in majority of the ‘lost’ cases.

Beside the advantage of saving normal tissue in the brain or extracranially, CK represents a huge leap forward in treating moving targets like cancer in the lung, liver or in the prostate. All these three organs, move during the radiotherapy.



The first patient, Master Shanka had very serious neurological complaints at the time when he came to Apollo. He was attended by Sr. Consultant Neurosurgeon Dr.Balamurugan. However his attempt to remove the haemangioblastoma from the patient’s brainstem was confined to fail due to the dangerously high vascularity which is the nature of that kind of tumors. But this surgical nightmare can be converted into an advantage with the help of High Precision Irradiation (HPI). High vascularity means high density of endothelial cells which are covering the inner surface of the vessels. These vulnerable cells can react with an overgrowth for the exposure of radiation.


Few months after the success full Stereotactic Radiosurgery with CK, part of the tumor has been obliterated its overall size started to come down.This is why the patient has improved and could resume his normal life.

Fate of a patient with inoperable lung cancer is practically known at the time of the diagnosis. Only a very minimal percentage of the inoperable lung cancer cases can be saved by the combination of conventional irradiation with chemotherapy. CK seems to bring a new hope for these patients. A 57 year old gentleman from the neighboring Srilanka successfully conquered one cancer 10 years ago with the help of Apollo Speciality Hospital. He came with hope again when an inoperable lung cancer in his chest was diagnosed. Chemotherapy has failed unfortunately. And then Cyberknife seemed to come for his rescue. High precision and short duration, biologically very intensive radiation has resulted in an impressive remission of his advanced lung cancer without any side effects. This aggressive cancer does have the capacity of invading the rest of the body. As a matter of fact the same has been observed with that particular patient too. But for him this is not the “end of the road”. A second CK treatment is planned to attend all the new sites of cancers shown on the PET CT. Highly sophisticated tools in radiation oncology do allow us to provide longer control with reasonable if not excellent quality of life even in an aggressive cancer.

There is a beautiful sentence told by Rabindranath Tagore about the disease in general. “DEATH DOES NOT HURT US, BUT DISEASE DOES, BECAUSE DISEASE CONSTANTLY REMINDS US OF HEALTH AND YET WITHOLDS IT FROM US.”

This is double true for cancer. Quality of life of a patient has to be one of the primary concerns of an oncologists. Many cancers have a tendency to migrate to the bone, to the spine. These metastatic lesions have the capacity to paralyze the patients by compressing the spinal cord. Chemotherapy frequently has only temporary control over the progress and so does conventional radiotherapy. But high precision in CK helps. We have the technical skill and opportunity to give high precision irradiation to the spine and to arrest this type of tumours even before they cause the extremely bad condition of transverse lesion of the spine. A Professor from George-Towns University in Washington DC said “by now we hardly deal with paralysis due to metastasis to the spine. It is being attended with CK at a curable and controllable stage and the patient will not be confined to bed for the rest of his/her life.


The basic question: ‘How cancer can be tamed in general’ still remains unanswered. But the tremendous progress gives hope for both temporary control with good quality of life and for cure in many cases. It is our job and duty to know about new developments and to apply them with wisdom. This conference was all about this.

CYBERKNIFE SUCCESS STORY - TREATMENT OF PROSTATE CANCER

CYBERKNIFE SUCCESS STORY - TREATMENT OF PROSTATE CANCER

DR.MAHADEV Senior Consultant, Radiation Oncology

71 Yrs old Mr.Birendra Singh from Gopalganj, Bihar was devastated when he was diagnosed to have Prostate cancer. He had gone to his urologist for just a routine checkup because he was having difficulty in passing urine for the last couple of months. A routine PSA done was in the range of 15ng/ml. A transrectal biopsy revealed grade 2 adenocarcinoma of the prostate gland with a Gleason’s score of 3+4.

Mr.Singh went to Delhi for an opinion. He consulted various doctors which included several urologists, surgical oncologists and radiation oncologists.The options given to him included wait and watch, bilateral orchidectomy(removal of both testis), Radical prostatectomy, Brachytherapy(seed /HDR implant).The opinions were so varied that the family could not take a decision for 3 months.

Patient also consulted Apollo Hospitals at Ranchi in Jharkhand where he was advised to go to Apollo Speciality Hospital Chennai as all the treatment options were available there and he was also told that a full team of doctors decide on a treatment in the tumor board.

Mr Birendra Singh’s nephew who lives in the United States, meanwhile contacted his uncle from there and told him about a new treatment called the cyberknife which he had read on the internet. His nephew was very impressed by what he had read on the net- outpatient treatment, non-invasive, very precise radiation delivered robotically and just 5 sittings with practically no side effects. He asked his uncle to come to US for treatment as he thought it was unlikely that this treatment option would be available in India.

After going through all the treatment options Mr.Birendra Singh decided he would go in for Cyberknife as he found that to be the best treatment modality in his opinion. He visited Chennai in March 2009 to take a final decision. We had just then started using Cyberknife and we told him that the latest version of Cyberknife is now available here. He was told that the cost of cyberknife would be around 40,000 US dollars in US. We told him that the cost of treatment here would be Rs 400,000.

As we had just started Cyberknife Mr Singh was anxious about our technical capability. But when he came to know that the entire team was trained at the Stanford University, California, where actually the cyberknife was invented, he immediately decided to have the treatment here.

The first step in the treatment process was counselling him about the various treatment aspects.This included explaining to him the various stages of the treatment preparation ,planning and execution.The expected benefits and the various side effects that can be expected was explained to him in detail.The side effects that are normally seen with this treatment can be increased frequeny of micturition and bowel movemens.Very rarely, rectal bleeding can be seen as a late effect of radiotherapy.

The second step was placing 5 gold fiducials into the prostate gland transperinealy under transrectal guidance which took about half an hour. These fiducials are necessary for the machine to track the prostate gland during the entire course of treatment. Normally, we have to wait for a week after placing the fiducials for doing the planning CT scan. This is necessary because in the first couple of days, the seeds can migrate.

The third step in his planning was the making of a special type of bed called Vacloc for immobilization of the patient during treatment. Vacloc is a vacuum bed which takes the shape of the patient so that daily reproducibility of the patient in the same position can be achieved easily. This took about 10 minutes following which a CT scan was done with the patient lying in the vacloc in the treatment position.


Next, the Radiation oncologist contours the prostate gland, bladder and rectum. Then, the medical physicist puts on the treatment beams. The treatment plan was ready the next day and was reviewed by the oncologist and urologist.The treatment plan was finalized and the patient was asked to come for treatment the following day which happened to be a Tuesday. Patient was asked to have a light breakfast before 8 am and report for treatment at 10am.He was also asked to take a laxative the previous night and antacids.This preparation is a very important part of the treatment as improper bowel evacuation and gas in the bowel can interfere with the accuracy of the treatment.As cyberknife can achieve submillimeter target accuracy and continuously tracks the target while treatment ,it is absolutely essential that patients follow this preparatory regimen very carefully.Mr Singh was prescribed 5 treatment sittings on consecutive days.

Each treatment lasted for about 45-50 minutes and Mr.Birendra Singh completed his treatment on schedule on Saturday.He had initially booked his tickets for Sunday but as he did not have any side effects he preponed his journey to Saturday night.He was advised to have a PSA after 3 months which confirmed that the PSA had come down to normal values.

MR. BIRENDRA SINGH AFTER COMPLETING 5 TREATMENT SITTINGS

Mr.Singh Reported back to us in the first week of December. His PSA which was repeated was less that 1ng/ml which shows excellent response to treatment. There were practically no side effects during and after the treatment.



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Cyber Knife Radio surgery in Pediatric Patients

Cyber Knife Radio surgery in Pediatric Patients

Dr.R.Rathna Devi, Sr. Consultant Radiation Oncologist

“One little girl told me “ I want to go to school” she was one of my early pediatric patient with AVM for the new facility, Cyber Knife. That’s what was on her mind. And that’s what she did. She went to school immediately after her treatment. This made a tremendous difference to the family and to the child, and I was very happy to have offered her this”.



Cyber Knife radio surgery has a great advantage in treatment of pediatric intra and extra cranial lesions which includes non – invasive immobilization, low radiotherapy exposure to the developing normal brain other tissues and ability to fractionate the treatment.

Young patients in the past were usually required to wear a of head frame (Gamma Knife, other kind of radiosurgery equipments), and had to remain anesthetized during the entire, often day long procedure.


These procedures uses rigid metal frame attached directly to the patient’s skull to orient the radiation beams, making it difficult to treat young children with small/ fragile heads. Because the frame cannot be removed between the initial imaging and subsequent treatment, doctors also had to work fast with the other types of radio surgery. With the clock ticking, we had to place the frame, perform CT/MRI or other imaging studies; get everyone involved to meet, plan the treatment and then treat the patient, while the patient is intubated and asleep. This is not an optimal situation.

Fortunately now at Apollo Speciality Hospital we can treat young patients (who can hop off the table and go home or to school) after the initial imaging step while we plan the treatment strategy. The non invasive process uses tiny focused beams of radiation to perform radio surgery on a patients head or body. This technique allows us (Doctors) to attack trouble spots deep within the brain while minimizing the dose of radiation to surrounding healthy tissue. This is particularly important in children, whose brain is still developing.

ADVANTAGE - CYBERKNIFE

Cyberknife which was developed by John Adler, uses a mesh mask to stabilize the head. The technology tracks any unintentional movement on the part of the patient and adjusts the radiation path as necessary. Children who can understand the importance of holding still can undergo the treatment while conscious, younger kids can have short term anesthesia for approximately hour – long diagnostic and treatment session. The recovery from anesthesia is usually quicker because they don’t usually have to be intubated.

At Apollo specialty hospital, till date we had the opportunity to treat 11 children with Cyberknife radio surgery. Our first Cyberknife patient was a pediatric patient with cervico medullary haemangioblastoma 15 years male patient from Tripura . He presented with neck pain, poor cough reflex, and difficulty in swallowing and upper limb tingling sensation. Investigations revealed cervico medullary expansile lesion involving medulla to C2 C3 level.

He underwent occipito cervical craniotomy and decompression, because of high vascularity, surgery was abandoned. He underwent Cyberknife radio surgery between 24th to 26th March 2009. In the first follow up after 3 months, his symptoms completely disappeared follow up MRI showed reduction in size of lesion and contrast enhancing portion of the lesion reduced significantly.

This boy really benefited out of Cyberknife radio surgery. Treating only the affected area with out affecting adjacent brain tissue. He is due for his 10th Std board exam now.

Intracranial


We have treated 4 patients with AVM, and other treated indications include :


1 patient with Supracellular Hemartoma


1 patient with pineliocytoma


1 patient with Recurrent Meningioma


1 patient with Brainstem Glioma


1 patient with Pilocytic astrocytoma (residual)


Spine


1 patient with vertebral Haemangioma


To conclude, Cyberknife: represents an entirely new approach to radiosurgery. It is the only system that combines robotics, and advanced image guidance to deliver frameless radio surgery.

Cyberknife features robotic arm and proprietary image guided technology. The robotic arm is computer controlled and has an arm movement precision of 0.5mm.

Greatest advantage is an out patient basis treatment.


FOR MORE INFORMATION REGARDING CYBERKNIFE TREATMENT IN PEDIATRIC CASES YOU MAY BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com

CYBERKNIFE IN LUNG CANCER

Dr.Sanjay Chandrasekar, Senior Consultant Radiation Oncology presented on Cyberknife in Lung Cancer in the 11th Napcon 2009 (National Conference of Indian Chest Soceity ) conference in Calicut betweeb 5-8th November 2009.

The excerpts from his presentation on Cyberknife in Lung Cancer are :

FOR MORE INFORMATION ON CYBERKNIFE TREATMENT IN LUNG CANCER YOU CAN BLOG YOUR COMMENTS OR WRITE TO lakshmipriya_b@apollohospitals.com

CME on Robotic RadioSurgery in Brain & Spine - Recent Advances by Prof. John Adler on 5th October

During a recent visit to Chennai , on the 5th of October 2009 ,Professor Dr. John Adler  presented a  CME on Robotic RadioSurgery in Brain & Spine - Recent Advances  was conducted . Around 65 Drs attended (Neuro Physicians & Surgeons / Spine Surgeons / Radiation Oncologists from different institutions in Chennai) attended the CME and were benefitted by the insights and guidance of Dr. Adler, on the usage of Cyberknife in Neurosurgery.

Some of the photographs taken  during the CME

CYBERKNIFE® AT APOLLO – THE FIRST SUCCESS STORY

PROFILE

Master Sankha Subhra Dey, 15 year old bright young boy from Tripura and the only son of Mr. Bimalendu Dey visited Apollo Speciality Cancer Hospital, Chennai which houses the Asia Pacific’s first and latest Cyberknife® on the 31st of January 2009.

Mr. Bimalendu Dey, is a School Teacher with Govt of Tripura and belonged to the lower income group. When his son was first brought to the Apollo Hospitals, he complained of severe headache, and was registered with our Neurosurgery department.

Before coming to Apollo, the boy was treated at local hospitals in Tripura but there was no relief. Instead his symptoms worsened. That was when, Mr. Bimalendu Dey decided to bring him to Apollo Speciality Cancer Hospital. He was seen by one of our eminent Neurosurgeon Dr.M.Balamurugan.

SYMPTOMS

At the time of presentation patient had neck pain, weakness of upper limb associated with tingling numbness. Poor cough reflex and difficulty in swallowing was also seen. His motor sensation and power was 4/5 all four limbs.


DIAGNOSIS
He was hospitalized and investigated MRI brain Angio and Venogram revealed expansile lesion involving the medulla and Cervico medullary Junction extending to C2 -C3 level.



TREATMENT
After Pre – operative wok up and consent the patient was taken up for tracheostemy , and occipito-cervical craniotomy, decompression was performed.
During surgery highly vascularised tumor seen in brainstem, possibility of Hemangioblastoma was decided.Surgery was abandoned because of high vascularity,critical position and poor out come. His post-op period was uneventful.

Patient was referred to Dr.RathnaDevi, Senior Consultant Radiation Oncology for possibility of Radiation therapy treatment. This was the time that Apollo Hospital had introduced Cyberknife® system the world’s first and only robotic radiosurgery system designed to treat tumors with sub milli-meter accuracy. Cyberknife can also be used to treat tumors previously considered inoperable.The location of the lesion was in a critical area of the brain stem. It was a challenge to treat the lesion with such accuracy without affecting other adjacent critical structures which was possible only with CyberKnife radiosurgery.



A TOUGH DECISION MADE EASY!



As there was no possibility of surgery the only option of treatment was Radiosurgery.

Having a thought that Master Sankha Subhra Dey could find an answer in Cyberknife® ® treatment, Dr.Rathna Devi discussed the case in Cyberknife® ® advisory board, and the same was opined and agreed by the Cyberknife® board.

The doctor also posted the case in the CK society and opinion was sought with renowned CK specialists all over the world.Fortunately, Dr.John Adler (Father of Cyberknife® ) visited our hospital to inaugurate Cyberknife®. His valuable advise was also sought.

Patient and his father was counseled about Cyberknife treatment and that was the only option of treatment. They understood clearly and consented for Cyberknife treatment and even waited till the Cyberknife machine was commissioned and functional. HE WAS OUR 1ST CYBERKNIFE PATIENT.

CYBERKNIFE TREATMENT

After proper immobilization and imaging planning was done taking utmost care to protect the critical organs which were at risk. An additional benefit with Cyberknife is that it can be done on a Outpatient basis. After successful planning and verification, treatment delivery was done. Patient underwent 21Gy in three sittings from 24th to 26th March. Patient tolerated the treatment well.

This was also a moment when we saw the deep emotional bonding in the family. Master Sankha Subhra Dey was unable to speak during treatment because of he had tracheostomy. During treatment the patient and the father always communicated with their eyes. (Guess that was their special language and it carried so much of emotions). Of course, they had lot of hope and trust on us . They were extremely cooperative as well.



FOLLOW UP

Patient reported for his first follow up after three months. There was a dramatic improvement in his health. His cough reflex improved. Dysphagia (difficulty in swallowing)disappeared. There was no weakness of upper limbs and no neck pain.

Tracheotomy tube was removed. He had a good weight gain, his skin and eyes were literally glowing. He was handsome and beaming with confidence.

Follow up MRI revealed reduction in the size of lesion, contrast enhancing portion of the lesion has reduced significantly.

This young boy who was unfortunately suffering of brain stem SOL, and had no options of surgery was benefited by Cyberknife Robotic Radio Surgery. The patient who comes from a middle income group for whom the same treatment abroad would have been next to impossible could find a cure……………. a treatment ………………. Fortunately at Apollo!


Treatment at par with international standards at a very affordable price.. made this a fantastic first success story that every Apolloites are very proud to talk about………………..!, TOUCHING LIVES


         CT PICTURES BEFORE AND AFTER CYBERKNIFE


 LESION IN THE BRAIN STEM SIGNIFICANT REDUCTION AFTER CK
                                             

CONTRAST ENHANCING PORTION         ALMOST DISAPPEARED

FOR MORE INFORMATION PLEASE WRITE TO lakshmipriya_b@apollohospitals.com

CYBERKNIFE IN TREATMENT OF ACOUSTIC NEUROMAS

CYBERKNIFE IN TREATMENT OF ACOUSTIC NEUROMAS

Dr.Sanjay Chandrasekhar – Senior Consultant Radiation Oncology


Acoustic Neuromas have always been considered ideal targets for radiosurgery.
These tumors generally cause diminished hearing or loss of hearing, giddiness or dizziness, loss of equilibrium or balance and facial nerve paralysis.

Traditionally these tumors have been treated either surgically or with radiation. Surgical removal of these tumors has been associated occasionally with injury to the facial nerve.

Either conventional radiotherapy, Stereotactic radio therapy or single fraction Gamma knife or X-knife radio surgery have been used for patients with Acoustic Neuromas depending on size, symptoms at presentation, cost factor etc.,

Small Acoustic Neuromas are considered ideal targets for stereotactic radiosurgery. Large series of such patients treated with either Gamma Knife or X-knife have been published. The earlier experience with Gamma knife or X- Knife in treating these tumors with a single fraction radio surgery had yielded reasonably good responses and long term tumor control rates.

The incidence of facial nerve injury and diminution of hearing in a sizeable number of patients while using single high dose radio surgery prompted investigators to explore the possibility of using fractionated radio surgery of Acoustic Neuromas.

Fractionated radio surgery has evolved recently with the increased use of the CyberKnife as a potent tool in the management of these benign tumors. The frameless feature of the cyberknife has resulted in bettering patient compliance and comfort. The entire treatment is completed over 3-5 days on an outpatient basis. In addition, the entire treatment is robotically guided increasing the accuracy to a sub millimeter level.

The cyberknife experts worldwide are convinced about the efficacy and safety of the use of fractionated Cyberknife radiosurgery in the treatment of Acosutic Neuromas. The long term tumor control rates and hearing preservation rates have been extremely satisfactory according to them(University of Stanford experience).

You can also read a success story through the following link : accuray.com/uploadedFiles/Suzanne_Patient_Story.pdf