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

DR. SURESH H.ADVANI at APOLLO SPECIALITY CANCER HOSPITAL - CYBERKNIFE CENTER.

Padma Bhushan Prof.(Dr.) Suresh H.Advani , a well known renowned specialist in Oncology visited Apollo Speciality Cancer Hospital recently.

He visited our Cyberknife facility and during a recent interview to" News Today "had the following to say :
‘I used to refer cancer patients to Malaysia where the CyberKnife procedure was available and now Apollo Hospitals, Chennai, has acquired the latest Asia Pacific’s most advanced CyberKnife robotic radiosurgery system, PET scanning, MRI, Radiography, bone marrow transplant unit which is to be set up at the earliest, with expertise in the field, all under one roof that makes Chennai city the medical destination,’ said Dr Suresh Advani


To read the interview with dr. Suresh H,Advanui please log on to www.newstodaynet.com  Monday, 23 November, 2009



 
 
It was our previlige to have him here and get his valued opinion

DR.ADVANI in the center, with the cyberknife panel of  radiation oncologits at Apollo Speciality Cancer Hospital .

 
 
 
FOR FURTHER INFORMATION ON CYBERKNIFE TREATMENT,PLEASE  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

TRIGEMINAL NEURALGIA

CYBERKNIFE IN TREATMENT OF TRIGEMINAL NEURALGIA


Dr.M.Balamurugan, Senior Consultant - Neuro Surgery

"The Suicide Disease" or tic douloureux(also known as prosopalgia) is a neuropathic disorder of the facial trigeminal nerve. The trigeminal nerve the fifth cranial nerve, is responsible for sensory data (pressure, tempereature & pain) and also responsible for the motor function of the muscles involved in chewing but not facial expression.

SYMPTOMS

The disorder is characterised by episodes of intense facial pain that usually last from a few seconds to several minutes or hours. The attacks are said to feel like stabbing electric shocks, burning, pressing, crushing, exploding or shooting pain that becomes intractable.

Unfortunately, the symptoms of trigeminal neuralgia are often falsely attributed to a pathology of dental origin. Because of this difficulty, many patients go untreated unless a correct diagnosis is made.
There is evidence that points towards the need to quickly treat and diagnose TN. It is thought that the longer a patient suffers from TN, the harder it may be to reverse the neural pathways associated with the pain. Therefore it is essential that physicians are made aware of the seriousness of TN and the level of pain that their patient

TREATMENT OPTIONS

Medical treatment may involve usage of Anticonvulsants such as carbamazepine, oxcarbazepine, topiramate, phenytoin, or gabapentin and sometimes low doses of some antidepressants such as amytriptiline is used.

Surgically there are five options available . Of the five surgical options, the microvascular decompression is the only one aimed at fixing the presumed cause of the pain. Three other procedures use needles or catheters that enter through the face into the opening where the nerve first splits into its three divisions. Excellent success rates using a cost effective percutaneous surgical procedure known as balloon compression are available. This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression.

Other options involve using glycerol injections and radiofrequency rhizotomies. Glycerol injections involve injecting an alcohol-like substance into the cavern that bathes the nerve near its junction. This liquid is corrosive to the nerve fibers and can mildly injure the nerve enough to hinder the errant pain signals. In a radiofrequency rhizotomy, the surgeon uses an electrode to heat the selected division or divisions of the nerve. Done well, this procedure can target the exact regions of the errant pain triggers and disable them with minimal numbness.

Stereotactic Radio Surgery The nerve can also be damaged to prevent pain signal transmission using Gamma Knife or a linear accelerator-based radiation therapy (e.g. Trilogy, Novalis, CyberKnife).

Cyberknife Radiosurgery : Of these, the development of CyberKnife radiosurgery (Accuray, Inc., Sunnyvale, CA) in 1994 added a promising new treatment option for this disease. Using noninvasive head immobilization and advanced image-guidance technology, the CyberKnife dynamically tracks skull position and orientation during treatment, thereby ensuring targeting accuracy throughout the entire procedure, and patients are spared the discomfort of frame fixation onto their skulls. CyberKnife radiosurgery offers the ability to deliver nonisocentric, conformal and homogeneous radiation doses to nonspherical structures such as the trigeminal nerve. There are no risks of infection, cerebrospinal fluid leak or wound healing from Cyberknife Radiosurgery. However, some patients may develop additional numbness in the face or may experience abnormal facial sensations. This occurs in less than 10% of patients.

For more information please write to : lakshmipriya_b@apollohospitals.com;

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