Feasibility of frameless single-fraction stereotactic radiosurgery for spinal lesions

Object The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. Its use for the treatment of spinal lesions has been limited by the availability of effective target-immobilizing devices. In this study the authors evaluated the CyberKnife Real-Time Image-Guided Radiosurgery System for spinal lesion treatment involving a single-fraction radiosurgical technique. Methods This frameless image-guided radiosurgery system uses the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the target without the use of frame-based fixation. Cervical lesions were located and tracked relative to osseous skull landmarks; lower spinal lesions were tracked relative to percutaneously placed gold fiducial bone markers. Fifty-six spinal lesions in 46 consecutive patients were treated using single-fraction radiosurgery (26 cervical, 15 thoracic, and 11 lumbar, and four sacral). There were 11 benign and 45 metastatic lesions. Tumor volume ranged from 0.3 to 168 ml (mean 26.7 ml). Thirty-one lesions had previously received external-beam radiotherapy with maximum spinal cord doses. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Tumor dose was maintained at 12 to 18 Gy to the 80% isodose line; spinal cord lesions receiving greater than 8 Gy ranged from 0 to 1.3 ml (mean 0.3 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Axial and radicular pain improved in all patients who were symptomatic prior to treatment. Conclusions Spinal stereotactic radiosurgery involving a frameless image-guided system was found to be feasible and safe. The major potential benefits of radiosurgical ablation of spinal lesions are short treatment time in an outpatient setting with rapid recovery and symptomatic response. This procedure offers a successful alternative therapeutic modality for the treatment of a variety of spinal lesions not amenable to open surgical techniques; the intervention can be performed in medically untreatable patients, lesions located in previously irradiated sites, or as an adjunct to surgery.

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CyberKnife frameless single-fraction stereotactic radiosurgery for benign tumors of the spine

Neurosurgical FOCUS ◽

10.3171/foc.2003.14.5.17 ◽

2003 ◽

Vol 14 (5) ◽

pp. 1-5 ◽

Cited By ~ 59

Author(s):

Peter C. Gerszten ◽

Cihat Ozhasoglu ◽

Steven A. Burton ◽

William J. Vogel ◽

Barbara A. Atkins ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Tumor Volume ◽

Surgical Techniques ◽

Outpatient Setting ◽

Neurological Deficits ◽

Benign Tumors ◽

Minimal Risk ◽

Single Fraction ◽

Spinal Lesions

Object The role of stereotactic radiosurgery in the treatment of benign intracranial lesions is well established. Its role in the treatment of benign spinal lesions is more limited. Benign spinal lesions should be amenable to radiosurgical treatment similar to their intracranial counterparts. In this study the authors evaluated the effectiveness of the CyberKnife for benign spinal lesions involving a single-fraction radiosurgical technique. Methods The CyberKnife is a frameless radiosurgery system in which an orthogonal pair of x-ray cameras is coupled to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, whereby the therapy beam is guided to the intended target without the use of frame-based fixation. Cervical spine lesions were located and tracked relative to skull osseous landmarks; lower spinal lesions were tracked relative to percutaneously placed fiducial bone markers. Fifteen patients underwent single-fraction radiosurgery (12 cervical, one thoracic, and two lumbar). Histological types included neurofibroma (five cases), paraganglioma (three cases), schwannoma (two cases), meningioma (two cases), spinal chordoma (two cases), and hemangioma (one case). Radiation dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographic tumor volume with no margin. The tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 16 Gy). Tumor volume ranged from 0.3 to 29.3 ml (mean 6.4 ml). Spinal canal volume receiving more than 8 Gy ranged from 0.0 to 0.9 ml (mean 0.2 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Pain improved in all patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging (mean 12 months). Conclusions Spinal stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of benign spinal lesions. Its major potential benefits are the relatively short treatment time in an outpatient setting and the minimal risk of side effects. This new technique offers an alternative therapeutic modality for the treatment of a variety of benign spinal neoplasms in cases in which surgery cannot be performed, in cases with previously irradiated sites, and in cases involving lesions not amenable to open surgical techniques or as an adjunct to surgery.

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CyberKnife frameless single-fraction stereotactic radiosurgery for tumors of the sacrum

Neurosurgical FOCUS ◽

10.3171/foc.2003.15.2.7 ◽

2003 ◽

Vol 15 (2) ◽

pp. 1-5 ◽

Cited By ~ 40

Author(s):

Peter C. Gerszten ◽

Cihat Ozhasoglu ◽

Steven A. Burton ◽

William C. Welch ◽

William J. Vogel ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Tumor Volume ◽

Cauda Equina ◽

Surgical Techniques ◽

Outpatient Setting ◽

Neurological Deficits ◽

Therapeutic Modality ◽

Radiation Toxicity ◽

Single Fraction

Object The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. The experience with radiosurgery for the treatment of spinal and sacral lesions is more limited. Sacral lesions should be amenable to radiosurgical treatment similar to that used for their intracranial counterparts. The authors evaluated a single-fraction radiosurgical technique performed using the CyberKnife Real-Time Image-Guided Radiosurgery System for the treatment of the sacral lesion. Methods The CyberKnife is a frameless radiosurgery system based on the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the intended target without the need for frame-based fixation. All sacral lesions were located and tracked for radiation delivery relative to fiducial bone markers placed percutaneously. Eighteen patients were treated with single-fraction radiosurgery. Tumor histology included one benign and 17 malignant tumors. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographically documented tumor volume with no margin. Tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 15 Gy). Tumor volume ranged from 23.6 to 187.4 ml (mean 90 ml). The volume of the cauda equina receiving greater than 8 Gy ranged from 0 to 1 ml (mean 0.1 ml). All patients underwent the procedure in an outpatient setting. No acute radiation toxicity or new neurological deficits occurred during the mean follow-up period of 6 months. Pain improved in all 13 patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging. Conclusions Stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of both benign and malignant sacral lesions. The major potential benefits of radiosurgical ablation of sacral lesions are relatively short treatment time in an outpatient setting and minimal or no side effects. This new technique offers a new and important therapeutic modality for the primary treatment of a variety of sacral tumors or for lesions not amenable to open surgical techniques.

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Image-guided radiosurgery in the treatment of spinal metastases

Neurosurgical FOCUS ◽

10.3171/foc.2001.11.6.7 ◽

2001 ◽

Vol 11 (6) ◽

pp. 1-7 ◽

Cited By ~ 45

Author(s):

Martin J. Murphy ◽

Steven Chang ◽

Iris Gibbs ◽

Quynh-Tu Le ◽

David Martin ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Therapeutic Option ◽

Spinal Metastases ◽

Target Volume ◽

Outpatient Setting ◽

Spinal Tumors ◽

High Dose ◽

Radiation Beam ◽

Image Guided ◽

Frameless Radiosurgery

Object The authors describe a new method for treating metastatic spinal tumors in which noninvasive, image-guided, frameless stereotactic radiosurgery is performed. Stereotactic radiosurgery delivers a high dose of radiation in a single or limited number of fractions to a lesion while maintaining delivery of a low dose to adjacent normal structures. Methods Image-guided radiosurgery was developed by coupling an orthogonal pair of real-time x-ray cameras to a dynamically manipulated robot-mounted linear accelerator that guides the radiation beam to treatment sites associated with radiographic landmarks. This procedure can be conducted in an outpatient setting without the use of frame-based skeletal fixation. The system relies on skeletal landmarks or implanted fiducial markers to locate treatment targets. Four patients with spinal metastases underwent radiosurgery with total prescription doses of 1000 to 1600 cGy in one or two fractions. Alignment of the treatment dose with the target volume was accurate to within 1.5 mm. During the course of each treatment fraction, patient movement was less than 0.5 mm on average. Dosimetry was highly conformal, with a demonstrated ability to deliver 1600 cGy to the perimeter of an irregular target volume while keeping exposure to the cord itself below 800 cGy. Conclusions These experiences indicate that frameless radiosurgery is a viable therapeutic option for metastatic spine disease.

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SU-FF-J-32: A Feasibility Study of Image-Guided Non-Invasive Single-Fraction Stereotactic Radiosurgery Using the 2D2D Match of An On-Board Imaging System

Medical Physics ◽

10.1118/1.2760537 ◽

2007 ◽

Vol 34 (6Part5) ◽

pp. 2375-2375

Author(s):

J Chang ◽

W O'Meara ◽

J Mechalakos ◽

Y Yamada ◽

D Lovelock ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Feasibility Study ◽

Imaging System ◽

Single Fraction ◽

Non Invasive ◽

Image Guided

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Low risk of radiation myelopathy with relaxed spinal cord dose constraints in de novo, single fraction spine stereotactic radiosurgery

Radiotherapy and Oncology ◽

10.1016/j.radonc.2020.07.050 ◽

2020 ◽

Vol 152 ◽

pp. 49-55

Author(s):

Kevin Diao ◽

Juhee Song ◽

Peter F. Thall ◽

Gwendolyn J. McGinnis ◽

David Boyce-Fappiano ◽

...

Keyword(s):

Spinal Cord ◽

Stereotactic Radiosurgery ◽

De Novo ◽

Low Risk ◽

Radiation Myelopathy ◽

Single Fraction ◽

Dose Constraints

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The use of image guided laser interstitial thermotherapy to supplement spine stereotactic radiosurgery to manage metastatic epidural spinal cord compression: Proof of concept and dosimetric analysis

Practical Radiation Oncology ◽

10.1016/j.prro.2015.09.014 ◽

2016 ◽

Vol 6 (2) ◽

pp. e35-e38 ◽

Cited By ~ 5

Author(s):

Amol J. Ghia ◽

Neal C. Rebueno ◽

Jing Li ◽

Paul D. Brown ◽

Lawrence D. Rhines ◽

...

Keyword(s):

Spinal Cord ◽

Stereotactic Radiosurgery ◽

Spinal Cord Compression ◽

Cord Compression ◽

Proof Of Concept ◽

Image Guided ◽

Dosimetric Analysis ◽

Interstitial Thermotherapy

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A REVIEW OF IMAGE-GUIDED INTENSITY-MODULATED RADIOTHERAPY FOR SPINAL TUMORS

Neurosurgery ◽

10.1227/01.neu.0000279970.10309.b5 ◽

2007 ◽

Vol 61 (2) ◽

pp. 226-235 ◽

Cited By ~ 56

Author(s):

Yoshiya Yamada ◽

D. Michael Lovelock ◽

Mark H. Bilsky

Keyword(s):

Spinal Cord ◽

Intensity Modulated Radiotherapy ◽

Spinal Tumors ◽

Tumor Control ◽

High Dose ◽

Single Fraction ◽

Image Guided ◽

Intensity Modulated ◽

Very High ◽

Dose Radiation

Abstract OBJECTIVE A new paradigm for the radiotherapeutic management of paraspinal tumors has emerged. Intensity-modulated radiotherapy (IMRT) has gained wide acceptance as a way of delivering highly conformal radiation to tumors. IMRT is capable of sparing sensitive structures such as the spinal cord of high-dose radiation even if only several millimeters away from the tumor. Image-guided treatment tools such as cone beam computed tomography coupled with IMRT have reduced treatment errors associated with traditional radiotherapy, making highly accurate and conformal treatment feasible. METHODS This review discusses the physics of image-guided radiotherapy, including immobilization, the radiobiological implications of hypofractionation, as well as outcomes. Image-guided technology has improved the accuracy of IMRT to within 2 mm of error. Thus, the marriage of image guidance with IMRT (IG IMRT) has allowed the safe treatment of spinal tumors to a high dose without increasing the risk of radiation-related toxicity. With the use of near real-time image-guided verification, very-high-dose radiation has been given for tumors in standard fractionation, hypofractionated, and single fraction schedules to doses beyond levels traditionally believed safe in terms of spinal cord tolerance. RESULTS Clinical results, in terms of treatment-related toxicity and tumor control, have been very favorable. With follow-up periods extending beyond 30 months, tumor control rates with single fraction IG IMRT (1800–2400 cGy) are in excess of 90%, regardless of histology, and without serious sequelae such as radiation myelopathy. Patients also report correspondingly high rates of palliation. Excellent results, both in terms of tumor control and minimal toxicity, have been consistently reported in the literature. CONCLUSION IG IMRT represents a significant technological advance. Paraspinal IG IMRT is proof of principle, making it possible to give very-high-dose radiation within close proximity to the spinal cord. By reducing treatment-related uncertainties, margins around tumors can be shortened, thereby reducing the volume of normal tissue that must be irradiated to tumoricidal doses, reducing the likelihood of toxicity. Similarly, higher doses of radiation can be administered safely, improving the likelihood of eradication. Dose escalation can be done to increase the likelihood of tumor cell kill without increasing the dose given to nearby sensitive structures.

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