Bell Cutting-Edge Technology Intracranial and Extracranial...

Cutting-Edge Technology:

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Cutting-Edge Technology

Cutting- Edge Technology:Intracranial and Extracranial Radiation Therapy

Kathleen Bell RN, MSN, OCNRebecca Knight-Heitkam, RN, BSN, CCRNAnnette Quinn, RN, MSN


Objectives:

Define irradiation technologies for treating intracranial and extracranial disease processes.Cite the role of the nurse when caring for the individual who receives irradiation for intracranial and extracranial disease processes.By using evidence based practice, distinguish the common acute and long term patient care management issues for the individual who receives irradiation for intracranial and extracranial disease processes.


Leksell Gamma Knife

The Gold StandardFor IntracranialNon-Invasive Treatment ofBrain Disorders

Rebecca Knight Heitkam, RN, BSN, CCRNManager, Gamma Knife CenterSaint Joseph’s Hospital of Atlanta


Radiation TherapyThe treatment of disease using penetrating beams of high energy waves or streams of particles called “radiation”Causes biological damage at the atomic level leading to cell deathThe radiation comes from special machines or radioactive substances and is aimed at disease targetsAlso known as “radiotherapy”, “x-ray therapy”, or “teletherapy”


Effects on the CellsKills cells or keeps them from growing

Cells are undamaged.

Cells die as a result of damage.Cells are damaged,

repair damage and operate abnormally.

Cells are damaged, repair damage and operate normally.


The Physics Behind Radiation Therapy

Ionizing RadiationNeutrons and

Protons

Electrons

Ionizing Radiation

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Ionizing Radiation - radiation with enough energy to remove an electron from an unstable atom.

Ejected Electron


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Creating the EnergyThe Atom

Nucleus of + charges (protons) and neutral charges (neutrons)Orbit of – charges (electrons)Equal number of protons and electrons ensures neutral charge of atom


Unstable Atoms (Radioactive)Emit excess energy or massEmissions called “radiation”


Two Types of Ionizing RaysParticles

Includes alpha rays and beta raysWaves (electromagnetic)

Includes x-rays, gamma rays, light, etc.Ionizing RadiationRadioactive Atom

Alpha Particle

Neutron Particle

Beta Particle

Gamma Ray

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How The Ionizing Ray BeginsElectrons are “knocked off” the atom, causing the atom to become charged (or “ionized”)Radiation emission in particles

Alpha, beta, neutron radiation

Radiation emission in waves

Gamma rays, x-rays


Alpha ParticlesCharacteristics

• +2 charge

• 2 protons

• 2 neutrons

• Large mass

Range

• Very short

range

• 1" -2" in air

Shielding

• Paper

• Outer layer of skin

• Not able to penetrate clothes

Hazards

• Internal

Sources

• Plutonium

• Uranium

• Radium

• Thorium

• AmericiumAm-241

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Np-237

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α

Paper

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Beta ParticlesCharacteristics

• -1 charge

• Small mass

Range

• Short range• About 10'

in air • Able to

penetrate outer skin layer

Shielding

• Plastic safety glasses

• Thin metal

Hazards

• Skin and eyes

• Can be internal

+

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Paper AluminumH-3He-3

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β

Sources

• Radioisotopes

• Activation Products

• Sealed sources


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Electromagnetic Waves

Image not available


Gamma Rays and X-RaysLong-range, penetrating electromagnetic radiationShort wavelengths (high energy)Penetrate most materials and deep tissues of the bodyCalled “gamma rays” when they come from radioactive substances (i.e. cobalt)Called “x-rays” when produced by machines

Cobalt


Ionizing Radiation

Image not available


Measuring Radiation(conventional units or System International)

Depends upon whether you are measuring:

Radiation coming from a radioactive source

Curie (Ci) or Becquerel (Bq)

The radiation dose absorbed by a personRad (radiation absorbed dose) or Grey (Gy)

The biological risk to a person from exposure

Rem or Sievert (Sv)


Comparing Units of Measure

1 Sievert (Sv)=100 Rems

1 Grey (Gy)=100 Rads

37 billion Becquerel (Bq)

=1 Curie (Ci)

System International

=Conventional


Half-Life of Radioactive Materials

The time it takes an isotope to decay to half its original activityHalf-life is constant (not dependent on other factors)Half-life of Cobalt-60 is 5.3 years


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Goal of RadiotherapyCurative: sufficient radiation to eradicate malignant cells while limiting harmful radiation to normal tissuePalliative: sufficient radiation to relieve distressing symptoms


Types of Radiation DeliveryExternal Beam Therapy (or Teletherapy)

Intensity-Modulated Radiation Therapy (IMRT)Stereotactic Radiosurgery

Radioactive Implant (or Brachytherapy)


X-Ray TechnologyMachines produce x-ray waves utilizing a tube to aim waves at a particular body partX-rays pass through body and record image on filmSome tissues such as bone absorb x-rays well so image is white on x-ray filmOther tissues appear varying shades of grayStructures containing air (lungs) appear dark


Radiotherapy vs. Radiosurgery

Radiation therapy uses high energy light beams (X-rays or gamma rays) or charged particles (electron beams or proton beams) to damage critical biological molecules in lesion cells. Stereotactic radiosurgery (SRS) treats certain brain disorders with a precise delivery of a single high dose of radiation in a one-day session…involves the use of focused radiation beams delivered to a specific area of the brain to treat abnormalities, tumors or other functional disorders.


Radiation therapy and RadiosurgeryRadiation

dose

Target volumeSmaller LargerLow

High

Conventional Radiation Therapy

Conformal Radiation Therapy

Intensity Modulated Radiation Therapy

Image Guided Radiation Therapy

Stereotactic Radiation Therapy

Gamma Knife® surgery


Gamma Knife® surgery- refining the art of radiosurgery

Image not available


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History of Gamma KnifeProfessor Lars Leksell began research in 1950’s


Leksell Gamma Knife®Prof. Leksell invented and established radiosurgeryWith Elekta he developed Leksell Gamma Knife®- a dedicated tool for neurosurgical indicationsA tool designed by a surgeon - for the surgeonGamma Knife® surgery is today a complete treatment method used worldwide


Elekta providing precise solutions

““The tools used by the surgeon must be adapted to the task and where the human brain is concerned they cannot be too refined..””

Late Professor Lars Leksell

Image not available


Firsts1969: First acoustic neuroma patient treated by Dr. Leksell1970: First AVM treated by Gamma Knife by Dr. Steiner1987: First 201-source Gamma Knife in the U.S. in Pittsburgh (5th in the world)1997: Cyberknife developed by Dr. Adler1999: First Gamma Knife Model C2000: First Automatic Positioning System used on a patient



The delivery of a single, high dose of irradiation to a small and critically located intracranial volume through the intact skull

201 beams intersecting in one focal point

Image not available



Image not available


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Gamma Knife® surgery*More than 350,000 patients treated, over 40,000 annuallyUnsurpassed and proven clinical outcomeIncreased interest for functional disorders such as:

EpilepsyParkinson’s diseaseTrigeminal neuralgia

*approval of indications may vary between different countries


Treated with Leksell Gamma Knife®Neurological disorders

Malignant tumors 42%

Benign tumors 35%

Vasculardisorders 16%

Functional diseases 7%More than 300,000 patients treated


Examples of treated indicationsVascular- Arteriovenous

malformations

Tumors- Meningioma- Pituitary- Acoustic

Neuroma- Metastases- Gliomas

Functional- Trigeminal neuralgia

Research areas- Movement disorders- Intractable pain- Cluster headache- Epilepsy- Glaucoma- Uveal melanoma- OCD

Note: not for distribution in the US


Leksell Gamma Knife® -principles

Protective shielding

Spherical collimator helmet

Leksell Stereotactic System®Isocenter/Target in the brain

Automatic Positioning System™

201 sources of radiation


Leksell Gamma Knife®

Helmet supports

Automatic Positioning System

Treatment couch with mattress

Protection panels

Shielding doors

Shielding

Cobalt-60 sources

Plastic cover

Beam channelHelmet with collimators

Helmet in treatment position


The Six Steps to Gamma Knife® Surgery

1 Leksell Stereotactic System® 2 Clinical training* 3 Physics and radiobiology

4 Treatment planning 5 Technical training 6 System start* The clinical training is provided by leading neurosurgical institutions

Images not available


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An efficient procedure1. Frame fixation

2. Diagnostic imaging

3. Treatment planning

4. Treatment



1. Frame fixationPatient fixationEstablish spatial references


2. Diagnostic imaging

Digital image transfer to Leksell GammaPlan®

Leksell® coordinate frame provides optimal stereotactic localization

Supports all imaging modalities (CT, MRI, PET and Angiography)


3. Treatment planningLeksell GammaPlan®

provides:Surgical precision in your handIntuitive software dedicated for Gamma Knife® surgeryFast creation of optimal treatment plan


Leksell GammaPlan®

Tailor made surgical planningReal time dose calculationIntegrated dose plan optimizationFull 2D/3D image and dose display


Leksell GammaPlan® Wizard™

30 seconds

Interactive, real-time treatment plan optimization

Image not available


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Leksell GammaPlan® 4Cwith MultiView functionality

Facilitates pre-surgical tentative planning and post-operative follow-upCo-registration of any non-stereotactic and/or stereotactic image from CT, MR and PETSchaltenbrandt-Wahren brain atlas can by overlaid


4. TreatmentAutomatic treatment, supervised by redundant safety and verification systemsPatient and doctor communicate via audio visual system


5. Follow-upThe biological effect of Gamma Knife® surgery:

it distorts the DNA of the tumor cellsfor AVMs it causes the blood vessels to thicken and close off

The effects of the treatment will occur over a period of time


Reproducible resultsLow complication rateTreatment solution for inoperable patientsPeer reviewed scientific articles shows better or equal results compared with microsurgeryCombined treatment with microsurgery, radiotherapy and/or interventional radiology

Clinical Outcome


Documented good tumor controlLow morbidity rateFew if any side effectsVery low recurrence rateEffective on tumors that normally are not radiation sensitive

Clinical Outcome


A Documented Treatment Method

Clinically documented in over 2,000 peer reviewed papers


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Malformation Arteriovenous(AVM)

Courtesy: Douglas Kondziolka, M.D., M.Sc., FRCS, University of Pittsburgh, USA

Pre Gamma Knife®surgery

2 years post Gamma Knife®surgery


Acoustic Neuroma


2 years postPre 6 months post


1. 25,000 patients treated2. Preserves facial functions3. Preserves hearing 50 -70%4. Limit overall surgical risks

(CSF leaks, etc.)5. Better quality of life compared

to open surgery

Acoustic Neuroma Management


Meningioma

Courtesy: Ladislau Steiner, M.D., Ph.D. and Dheerendra Prasad, M.D.UVA Charlottesville, USA

Pre 2 years post


Meningioma

Dose plan with multiple isocenters - minimizing dose to optic chiasm

Image not available


Pituitary Adenoma

Courtesy: Ladislau Steiner, M.D., Ph.D., UVA Charlottesville, USA and Christer Lindquist, M.D., Ph.D., Karolinska Institute, Sweden

Pre 54 months post


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Metastasis

10 months post

Courtesy: Aizik Wolf, MD, Miami Neuroscience Center, USA

Pre


Metastatic Tumor

Figure A

Male, 65 years old, metastatic tumor of lung cancer origin. Pre Gamma Knife® surgery. Tumor + mass effect (compression of lateral ventricle)

Figure B

6 weeks post Gamma Knife® surgery. Tumor volume and mass effect reduced.

Courtesy: Jordan C. Grabel, M.D., Good Samaritan Hospital, West Palm Beach, Florida


Metastasis


Pre 2 months post


Astrocytoma

Courtesy: Ladislau Stenier M.D., Ph.D., Christer Lindquist, M.D., Ph.D. and Dheerendra Prasad M.D., UVA Charlottesville, USA

Pre 5 years post


Trigeminal Neuralgia

Courtesy: Douglas Kondziolka, MD, MSc, FRSC, University of Pittsburgh, USA

Dose plan 6 months post


Selectivity in Radiosurgery

Selectivity - describes how well a desired biological effect is achieved in a target volume without complications.

target biological effect

=


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Selectivity & ConformityConformity describes only how well the prescription dose is fitted to the target volume, whereas selectivity also takes irradiation to normal tissue into account.

Conformal

Conformal and selective

Image not available


Conformity of Dose to Target

The two pictures show the necessity for multiple isocenters in order to minimize dose delivered to normal tissue.

target target


Conformity of Dose to Target

PIV/TV = Conformity of the prescribed dose to the target volume

Source: Ed Shaw, IJROBP, Vol. 34, No. 3, 1996

Single isocenter Two isocenters

PIV/TV = 2.7 PIV/TV = 1.4

Prescription isodose volume

TUMOR

TUMOR


Years of Clinical Experience

1968 - The first prototype of Leksell Gamma Knife® was installed in Stockholm, Sweden.

1999 - Elekta refines the Art of radiosurgery by introducing Leksell Gamma Knife® C, with the robotic Automatic Positioning System™.

2004 - Elekta introduces the next generation Leksell Gamma Knife® 4C, including enhanced treatment software.



Leksell Gamma Knife®>200 systems installed worldwide

Europe - 13%

North America - 45%

Latin America - 1%

Middle East - 2%

China - 7%

Japan - 22%

Other Asia - 10%


Gamma Knife® Surgery

Improves quality of lifeEnhances clinical outcomeProvides cost effectiveness


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Quality of Life

Non-invasiveLess traumaFaster recoveryMinimal hospitalizationFewer complications

Documented efficacy


Saves Cost and Enhances Quality of Life

TimeSymptom Diagnosis

Open surgery

Days in ICU

Weeks ofhospitalization

Several weeksconvalescence

Gamma Knife®surgery


Cost effectivenessFaster recovery to normal lifeReduced costs per patientLarge patient through-putNo intensive and minimal post-operative careFew support staff requiredLow operating costReliable and documented long equipment lifetime


Automatic Positioning System™

A refined robotic system making minimal adjustments of the patient’s head in relation to the beams’isocenterOptimizes the radiation dose in relation to shape and size of the target Treats with sub-millimeter accuracyReduces radiation to healthy tissue


The Most Accurate

0.48mmRadiological accuracy plus imaging inaccuracies

Total Clinical Accuracy2)

0.15mm Avarage (Guaranteed to <0.50mm)

Accuracy of the system, including mechanical accuracy plus beam delivery accuracy

Radiological Accuracy1)

<0.3mmThe sum of all mechanical tolerances

Mechanical Accuracy

Leksell Gamma KnifeDefinitionType of accuracy

1) The figure is based on 332 meausurments over a period of two years on 189 installed systems. 2) Mack, Kreiner et.al ”Quality assurance in stereotactic space. A system for verifying the accuracy of aim

in radiosurgery”. Medical Physics 29:4. April 2002 . Based on 170 measurments over 5 yearsCutting-Edge Technology

Sharing and Driving Clinical ExperienceLeksell Gamma Knife® Society

Mission - further define and expand the role of Gamma Knife® surgery in the treatment of intracranial disorders¬ Bi-annual meetings¬ More than 2,000 members¬ 200 scientific abstracts/meeting¬ Proceedings presented in

Journal of Neurosurgery


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Gamma Knife at Saint Joseph’s

Image not available


Intracranial Linear Accelerator (LINAC ®):Stereotactic Radiosurgery Stereotactic Radiotherapy

Kathleen Bell RN, MSN, OCN®Clinical Nurse Specialist/Nurse ManagerSpectrum HealthGrand Rapids, Michigan


Radiosurgery vs. Radiotherapy

Radiation therapy uses high energy to damage critical biological molecules in lesion cells. Stereotactic radiosurgery (SRS) uses a precise delivery of a single high dose of radiation in a one-day Stereotactic radiotherapy (SRT) provides the same effect of radiation as radiosurgery, but it is delivered in smaller dose over a series or treatments.


Radiobiology of LINAC ® :Radiosurgery/radiotherapy


LINAC® verses GAMMA Knife®~ Source/Administration

www.uhseast.com/ images/gamma_1.jpg

GANTRY

MULTIPLE

SOURCES

Image not available


LINAC® Based Evolution

BA

Image not available


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Indications LINAC ® Based Radiosurgery/radiotherapy….

Patient SelectionSmall tumors

< 3 cm in diameterWell circumscribed

High Karnofsky scale


LINAC® Based:Malignant Diseases

Post OperativeGlioblastoma multiformeMalignant astrocytoma

Grade 3 and grade 4Malignant glioma or gliosarcoma

www.flash.net/ ~drrad/tf/010598a.jpg

www.neuropat.dote.hu/ jpeg/tumor/3gliobl1.jpg

Image not available


LINAC® Based:Malignant Diseases

Brain metastasesSingle verses multiple

www.uwo.ca/.../pocketbook/ pictures/met.jpg www.uwo.ca/.../pocketbook/ pictures/mets.jpg



Intersection of Beams

Image not available


Multiple Lesions

Image not available


LINAC® Based: Benign Disorders

Arteriovenous Malformations (AVM)MenigiomoaIntractable Typical Trigeminal Neuralgia (TMJ)

www.medgadget.com/ archives/img/AVM.jpg


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Arteriovenous Malformations (AVM)

NeuritisImage not available


BrainLab® Frame System

Image not available


Patient Experience: Frame placement for SRS

B

CD

AImages not available


Patient ExperienceMask Placement for SRT

A

C

B



Treatment PlanningCT and or MRI scan fusionHeadframe


Treatment Experience

Image not available


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Role of the NursePatient Education:

side effects environmental or sensory experience of the treatment processEvaluate support systems


Nursing Role:Symptom Management Assessment and Intervention

AnxietyFear Claustrophobia

Pain management Patient PositioningHead frame placement


Nursing Role:Symptom Management Assessment and Intervention

NauseaDiseaseMedication related


Follow up Care and Monitoring

Nursing RoleRadiologic Studies

Non-malignantMalignant

Health care provider MonitoringNon-malignantMalignant


LINAC®: Evidence BasedPatient Care Management

Short TermSymptom Management Intervention

Long TermRadiation Necrosis

images.medscape.com/.../ thumb-ar498295.fig16.gif


Short Term/Acute SymptomsPhysical

Discomfort (pin site)Skin irritation and hair loss at the pin site

Nausea and/or vomitingCorrelation of pre-treatment symptoms with that of expected post-treatment symptoms.


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Long Term/Chronic SymptomsPhysical

Radiation Necrosis, which may includeSwelling, headaches, seizures and confusion

Correlation of pre-treatment symptoms with that of expected post-treatment symptoms.


LINAC® Based Treatment Outcomes of Care

Tumor ResponseQuality of LifeFuture research


Radiation Oncology at Spectrum Health.


Extracranial Stereotactic Radiosurgery

Annette Quinn, MSN, RNProgram Manager, University of Pittsburgh Medical Center


Stereotactic Radiosurgery

Using stereotactic techniques, give a lethal dose of ionizing radiation to the

target, while minimizing the toxic radiation to the surrounding tissue

=High doses of radiation to defined

target volumes


Basic techniqueMultiple radiation beams converge on the lesionAt the intersection a high dose is delivered, while the surrounding tissue receives a minimal dose


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Linear acceleratorsVarious systems:

X-knife®Novalis®Cyberknife®Trilogy®Synergy®


Linear accelerator-based SRSFrame based:

X-knifeNovalis

Frameless:CyberknifeTrilogySynergy


Image not available


Indications of SRSCells with neoplastic growth (benign and malignant)Vascular malformationLesionectomy: Functional Neurosurgery (trigeminal neuralgia)


Historical notesAccuray founded in 1992First patient treated in 1994CyberKnife System FDA Clearance –August 2001“To provide treatment planning and image-guided

radiosurgery and precision radiotherapy for lesions, tumors, and conditions anywhere in the body when radiation treatment is indicated.”


Image not available


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CyberKnife SystemThe CyberKnife® is a lightweight linear accelerator mounted on a robotic arm.

Does not rely on a fixed, invasive frame to keep the target organ immobile, thus can be used throughout the body

Two ceiling mounted cameras perform near real-time image tracking with 1 mm spatial accuracy.

The robot relates the identified lesion to radiographic landmarks (the patient’s skull).


Advantage of the Cyberknife

“Frameless” technique does not affect accuracy but allows for extracranial targetingAbility to fractionate treatment allows treatment of lesions abutting or involving radio-sensitive structures like the optic apparatus


CyberKnife6 MeV linac mounted on robot arm- 6 degrees of rotation

100 treatment positions (nodes) with the possibility to use 1, 200 intersecting beams of radiation

2 cross-firing X-ray cameras monitor patient position

Robot corrects for patient motion


CyberKnifeContinuously monitors and corrects for changes in patient position and motion by comparing pretreatment CT-based digitally reconstructed radiographs (DRR’s) to digital radiographs acquired throughout the radiosurgical treatment. Adjusts the position of the robotically targeted accelerator accordingly


CyberKnife Treatment (cont.)Radiosurgery in early days was only performed with single high doses of radiation.In contrast benefit of fractionation is well established in general radiotherapyCyberKnife’s capability to treat without head ring and to treat extracranial lesions has created a pathway for fractionation


ProcessOnce the fiducials have been implanted the treatment process consists of three basic steps 1) Treatment set-up,2) Treatment planning,3) Treatment delivery


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Patient set-up

Image not available


Treatment Set-upTechnology can compensate for minimal movements, larger patient movements are limited by fitting the patient with an immobilization device. A custom-fit, flexible mesh mask (for head/neck treatments) or body cradle is formed and is used to help minimize movement during the treatment and ensures patient comfort


Immobilization forIntracranial (or head & neck) lesions

Image not available


Immobilization for Extracranial Lesions

Image not available


What is a fiducial?Frameless radiosurgery allows ablation of tumors anywhere within the bodyFor intracranial lesions a comparison between bony profiles from DRRs and x-ray images is employed to position patient.Match the bony skull based landmarks from CT-based DRRs to those captured by the orthogonal pair of digital X-ray imagesPatient repostioned until perfect match is made.


Fiducials (cont.)For targets outside the skull there is a need to define an intermediate spatial reference system that is visible in CT and in conventional X-ray.For this purpose before CT scanning 3-6 gold fiducials are inserted in or around the tumor


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Fiducial Placement

Image not available


Image acquisition

Image not available


Treatment planning

Image not available


Treatment PlanningInverse treatment planning: Clinician specifies the total dose to be delivered to the tumor and sets boundaries to protect the critical structures. The software then determines the targeting positions and dose to be delivered from a particular targeting position.


Treatment DeliveryOccurs 1-5 days after planningPatient fitted with immobilization deviceimaging system acquires digital x-rays of the patient position. information is used to move the linear accelerator to the appropriate position robot moves and re-targets the linear accelerator at a large number of positions around the patient. At each position or “node”, a small radiation beam is delivered.


Treatment Delivery (cont)This process is repeated at 50 to 300 different positions around the patient to complete the treatment. The entire process is painless and typically takes between 30 to 120 minutes to deliver all radiation beams depending on tumor location. Most typically a patient can go home immediately upon completion and return to normal activities


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Defining AccuracyTraditional Definition: Mechanical Accuracy

New Definition: Total Clinical Accuracy

Tumor motion

Patient setup

Patient movement

Imaging (CT, MRI, etc.)

Treatment planning

Beam delivery

Total Clinical Accuracy


The Cyberknife “Team”

Radiation OncologistNeurosurgeon/surgeonPhysicistMedical OncologistNurseRadiation Therapist


Treatment Planning System

Image not available


Treatment Delivery

Image not available


Cyberknife Treatment

Image not available


Alignment Screen

Image not available


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Unlimited PotentialInstrument expands far beyond current 1,200 beams (targeting positions and approach angles)System utilizes CT and MRI scans for treatment planning


CyberKnife Clinical Indications Lesions adjacent to radiosensitive structuresMinimal or neurological deficitComplex-shaped lesions Previously irradiated lesions precluding further external beam irradiationRecurrent surgical lesionsLesions requiring difficult surgical approaches Patients who are too frail for surgery or refuse surgeryShort life expectancy


Clinical BenefitsStaged/Fractionated Radiosurgery

1-5 fractions/stagesLarger lesionsLesions next to critical structures/organs at risk

Improved Patient Quality of LifeShort treatment course: 1-5 days CyberKnife

Optimal for patients with limited life expectancyIncreased convenience

No infection riskNo general anesthesiaMinimal to no recovery time


Overview (as of December 2004)

Over 10,000 patients treated worldwide by CyberKnifeOver 100 peer-reviewed clinical & technical papers publishedTypes of lesions treated by CyberKnife

281Head/Neck/ENT415Nasopharynx466Lung

447Others, i.e. kidney, pelvis, etc

54Prostate79Bone

157Liver205Pancreas

1,505Spine7,192Intracranial

# PatientsLesion Type


Spinal RadiosurgeryClassically radio-resistant tumors: renal cell and melanomaIn previously radiated fields to avoid myelotoxicity


CyberKnife® Radiosurgery SystemBroad clinical application

Intracranial radiosurgeryExtracranial radiosurgery

SpineLungLiverPancreasProstateOther

Superior accuracySuperior conformalityProven clinical experience

Over 10,000 patients worldwideOver 100 papers published


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Other SRS systemsTrilogy® Stereotactic Beam on Linac

Image not available


Other Clinical ApplicationsPrimary & Recurrent H&N CancersLung TumorsLiver TumorsPara-aortic & Intra-abdominal tumorsPelvic tumors


FractionationUsed when large tumor volumes are involvedIn intracranial 3-5 fractions employed for volumes of 40-50 ml.Fractionate to preserve important functions where the intergrity of involved critical structures is of paramount importance. Such as acoustic neurmomas and visual acuityincranial base meningiomas


TrilogyTrilogy™ system can be used to deliver 3D conformal radiotherapy, IMRT, stereotactic radiosurgery, fractionated stereotactic radiation therapy, and intensity-modulated radiosurgery for cancer and neurosurgical treatment.


Trilogy (cont)23EX Clinac® linear accelerator, which has been enhanced for stereotactic applications that involve delivering higher doses of radiation to smaller areas over a shorter period of time.The Trilogy system is capable of delivering stereotactic radiosurgery by increasing its maximum dose delivery rate from 600 to 1000 monitor units (MU) per minute and by fine-tuning the Clinacisocenter, or focal point, to a 1-millimeter diameter sphere


Trilogy (cont)First patient treated in October of 2004Uses an On-Board Imager® to acquire images in real timeCan treat both intra-cranial and extra cranial lesionsUses an array to treat extracranial lesions


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Synergy Elekta Synergy® S will integrate high resolution beam shaping, stereotactic target localization utilizing Elekta® XVI (X-ray Volume Imaging) technology, and organ motion control. Instead of the usual multi-leaf collimator (MLC), Elekta Synergy® S will feature Beam Modulator which allows much finer resolution beam shaping. The combination of Elekta Synergy® with other purpose designed framing and fixation products will result in a clinically meaningful stereotactic solution for the localization and hypofractionated treatment of targets, both intra and extra-cranially. For single fraction intra-cranial treatment, the Gold Standard remains Leksell Gamma Knife®.


Nursing ImplicationsSide effects, as with any type of radiation therapy, are limited to the area being treatedprudent that the nurse in the radiosurgery suite review with the patient the side effects they may experience and pre-medicate the patient appropriately with anti-emetics or pain medicine as appropriate. For example patients receiving CyberKnife®

to the lower thoracic and lumbar spine should receive pre-medication for nausea and education that nausea, vomiting, diarrhea or abdominal cramping are potential side effects to treatment of this area.


Nursing ImplicationsPain management becomes important for nurses in radiosurgery suite especially those patients being treated for spinal lesions.Treatment can take any where from 30-2 hours and having a patient lie in position for that long a period may cause significant pain and discomfort.

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