CYBERKNIFE TREATMENT IN OVARIAN CARCINOMA

CYBERKNIFE TREATMENT IN OVARIAN CARCINOMA

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.

Source : http://www.cyberknifetampabay.org/

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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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BRAIN METASTASIS

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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Renal cell carcinoma

Patients with metastatic renal cell carcinoma (RCC) to the brain have a very poor prognosis of three months if left untreated. SRS is an effective treatment modality in numerous patients. This case exemplifies the utility of stereotactic radiosurgery (SRS) in prolonging survival and maintaining quality of life in a patient with RCC. This 64-year-old female patient initially presented to her primary care physician 22 months after a left nephrectomy for RCC with complaints of mild, intermittent headaches and difficulty with balance. An MRI revealed five cerebellar lesions suspicious for intracranial metastasis. The patient's first GKRS treatment targeted four lesions with 22 Gy at the 50% isodose line. She underwent a total of seven GKRS treatments over the next 60 months for recurrent metastases to the brain. 72 months and 12 months have now passed since her brain metastases were first discovered and since her last GKRS treatment, respectively, and this woman is alive with considerable quality of life and no evidence of metastatic reoccurrence. This case shows that repeated GKRS treatments, with minimal surgical intervention, can effectively treat multiple intracranial lesions in select patients, prolonging survival and avoiding iatrogenic neurocognitive decline while maintaining a high quality of life.

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