Lung metastases treated by CyberKnife image-guided robotic stereotactic radiosurgery at 41 months.

OBJECTIVES: Based on the reported success of stereotactic body radiotherapy in treating extracranial tumors, we used CyberKnife (Accuray Incorporated, Sunnyvale, CA) to treat patients with metastatic lung cancer. METHODS: This is a retrospective report of treatment details and outcomes of 35 patients, ranging in age from 33 to 91 years, with 69 histologically proven pulmonary metastases, treated by image-guided robotic stereotactic radiosurgery at the CyberKnife Center of Miami, between March 2004 and August 2007. Tumor volumes ranged from 0.7 mL to 152 mL. Total doses ranged from 5 to 60 Gy delivered in one to four fractions with an equivalent dose range from 6 to 110 Gy NTD delivered in 2-Gy fractions assuming an alpha/beta of 20 Gy. RESULTS: All patients tolerated radiosurgery well with fatigue as the main side effect. Grade 3 and grade 4 pulmonary toxic reactions were observed in one patient who had undergone a repeat treatment. Of the 35 treated patients, 27 (77%) were still alive at a median 18-month (range 2-41 mo) follow-up. Local control was 71% with 25 tumors showing a complete response, 16 a partial response, and 7 stable with disease. Eight had progressive disease. CONCLUSIONS: The delivery of precisely targeted radiation doses to lung tumors in a hypofractionated fashion is feasible and safe. Image-guided robotic stereotactic radiosurgery of pulmonary metastases with the CyberKnife achieves good rates of local disease control with limited toxicity to surrounding tissues and in many cases may be beneficial for patients for whom surgery is not an option.

Evaluation of CyberKnife Radiosurgery for Recurrent Trigeminal Neuralgia.

Stereotactic radiosurgery (SRS) has evolved as an accepted treatment for medication resistant trigeminal neuralgia. Initial results are very good but follow-up over three to five years shows a gradual return of pain in up to 50% of treated patients, often requiring further treatment. The results with repeat SRS using the isocentric Gamma Knife (GK) (Elekta, Stockholm, Sweden), especially in patients having initially good results, are very similar to the outcomes after the initial treatment although there is an increased risk of residual facial numbness secondary to the additional radiation dose to the trigeminal nerve. However, after 2000, non-isocentric SRS systems began to be used for treating trigeminal neuralgia including the CyberKnife (CK) (Accuray, Sunnyvale, California) as well as various linear accelerator (LINAC) based systems. This report specifically examines a series of recurrent trigeminal cases treated by the same group of physicians with the CK system. Similar doses and locations on the trigeminal nerve and/or the root entry zone were used for both initial and repeat SRS treatment regardless of system used. Although there are numerous series reporting the use of GK for recurrent treatment for recurrent trigeminal neuralgia, there are no series reviewing the results and long-term effectiveness using CK for repeat SRS for recurrent trigeminal pain. We reviewed 23 cases that had initial treatment for trigeminal neuralgia either surgically or with SRS with either the GK or CK and then a later second procedure only with CK. The follow-up after the second CK SRS ranged from three to 13 years found that the results are very similar to the multiple reports in the literature describing second or third SRS treatments with the GK. Results of repeat radiosurgery treatment of recurrent trigeminal neuralgia appear to be independent of the system used and are primarily based on proper target and dose to the trigeminal nerve.

CyberKnife radiosurgery for stage I lung cancer: results at 36 months.

PURPOSE: The aims of this study were to determine if image-guided robotic stereotactic radiosurgery by CyberKnife Radiosurgery System using ablative radiation doses achieves acceptable local control in medically inoperable patients with early non-small-cell lung cancer (NSCLC) and to evaluate disease-free survival, toxicity, and failure. CyberKnife can deliver the prescribed dose by using many different angles converging on the target, with real-time target tracking through a combined orthogonal radiograph imaging and optic motion tracking system (Synchrony). MATERIALS AND METHODS: A review of treatment details and outcomes for 59 patients, ranging in age from 51 years to 96 years, with 61 tumors with histologically proven cancers treated by image-guided robotic stereotactic radiosurgery at the CyberKnife Center of Miami between March 2004 and March 2007 is presented. Target localization and respiratory movement compensation were accomplished using a single fiducial marker placed within the tumor, and the X-Sight and Synchrony systems. Total doses ranged from 15 Gy to 67.5 Gy delivered in 1-5 fractions with an equivalent dose range of 24-110 Gy normalized treatment dose in 2 Gy fractions (alpha/beta = 20 Gy). RESULTS: Four patients with stage 1A NSCLC and 2 patients with stage 1B NSCLC had persistent or recurrent disease. All patients tolerated the radiosurgery well, fatigue being the main side effect. Of the 59 patients treated, 51 (86%) were still alive at 1-33-month follow-up. Eight patients have died, 2 of diseases other than cancer progression. CONCLUSION: The results indicate that the delivery of precisely targeted ablative radiation doses with surgical precision to limited treatment volumes of lung tumors in a hypofractionated fashion is feasible and safe. Image-guided robotic stereotactic radiosurgery of lung tumors with CyberKnife(R) achieves excellent rates of local disease control with limited toxicity to surrounding tissues and, in many cases, might be curative for patients for whom surgery is not an option.

Early results of CyberKnife image-guided robotic stereotactic radiosurgery for treatment of lung tumors.

OBJECTIVE: To determine if image-guided robotic stereotactic radiosurgery (IGR-SRS) by CyberKnife achieves acceptable local control in resectable but medically inoperable patients with non-small cell lung cancer (NSCLC) or pulmonary metastasis, and to evaluate control rates and toxicity. METHODS: Treatment details and outcomes were reviewed for 95 patients (age range 33-96 years) with 136 histologically proven cancers treated by IGR-SRS at the CyberKnife Center of Miami between March 2004 and March 2007. Tumor volumes ranged from 1.2 cc to 338 cc. Targeting was accomplished using combined skeletal alignment and real-time tracking via fiducials placed within the tumor. Total doses ranged from 15 to 67.5 Gy delivered in 1 to 5 fractions. RESULTS: Of the 95 patients treated, 78 (82%) are still alive at 1 to 36 months post-treatment. Nineteen patients have died, four from disease other than cancer progression. All patients but one achieved at least partial response to treatment and tolerated radiosurgery well. For the majority of our patients, fatigue had been the main side effect. CONCLUSIONS: The delivery of precisely targeted high radiation doses with surgical precision to lung tumors in a hypo-fractionated fashion is feasible and safe. Image-guided robotic stereotactic radiosurgery (IGR-SRS) of lung tumors with the CyberKnife achieves excellent rates of local disease control with limited toxicity to surrounding tissues, and in many cases may be curative for patients for whom surgery is not an option.

Delayed Development of Trigeminal Neuralgia after Radiosurgical Treatment of a Tentorial Meningioma.

Trigeminal neuralgia is a known symptom of the tumors and aberrant vessels near the trigeminal nerve and the tentorial notch. There are very few reports of delayed development of trigeminal neuralgia after radiosurgical treatment of a tumor in these areas. This is a case report of a patient treated with radiosurgery for radiation induced meningiomas, 30 years after childhood whole brain radiation. The largest tumor was adjacent to the pons and left trigeminal nerve but did not cause any direct neurologic symptoms or facial pain. Nine months after radiosurgical treatment of the tumors, the patient developed left sided typical trigeminal facial pain and magnetic resonance imaging (MRI) demonstrated the marked reduction in the tumor size. The patient was subsequently treated with radiosurgery to the Gasserian ganglion with a resolution of facial pain. This article reviews the unique characteristics and unusual response to the radiation induced meningiomas to radiosurgery. This is a case of rapid shrinkage of the tumor seen on follow-up MRI scans, concurrent with the development of facial pain, suggests that the rapid shrinkage led to traction on adhesions and related microvasculature changes adjacent to the tumor and trigeminal nerve roots causing the subsequent trigeminal neuralgia.

Treatment of early non-small cell lung cancer, stage IA, by image-guided robotic stereotactic radioablation--CyberKnife.

OBJECTIVE: To evaluate the efficacy of using image-guided robotic stereotactic radioablation as an alternative treatment modality for patients with surgically resectable, but medically inoperable, T1 N0 M0, stage IA non-small cell lung cancer. METHODS: Between January 2004 and May 2006, 19 patients, 11 women and 8 men ranging in age from 52 to 88 years, with stage IA non-small cell lung cancer were treated. Tumor volume ranged from 1.7 to 13 mL. Total doses ranged from 24 to 60 Gy delivered in 3 fractions. Eleven patients received 60 Gy. Real-time target localization was accomplished by radiographic detection of fiducial marker(s) implanted within the tumor combined with respiratory motion tracking. RESULTS: All patients tolerated radioablation well with fatigue as the main side effect. Fourteen patients are alive from 1 to 25 months posttreatment. Four patients died: 2 of comorbid disease and 2 of cancer progression (status post 60 and 55.5 Gy). Three patients developed grade I radiation pneumonitis. Two patients have stable disease. In 3 patients, cancer recurred in the planning treatment volume: in 2 patients after treatment with 60 Gy and in 1 patient after treatment with 55.5 Gy. One patient had local control in the target volume but developed metastasis to the ipsilateral hilum. Nine patients had a complete response and show no evidence of disease. CONCLUSIONS: In our early experience, stereotactic radioablation using the CyberKnife system appears to be a safe, minimally invasive, and effective modality for treating early stage lung cancer in patients with medically inoperable disease. Dose escalation and/or increasing the treatment volumes, with the aid of the high conformality of this technique, may help to achieve further improvements in these promising results.

Pruebas de tamizaje en el diagnostico precoz del cancer mamario / Screening tests in the early diagnosis of breast cancer

Las mujeres en quienes se diagnostica el cancer mamario de manera precoz ya sea por autoexamen, examen medico o por mamografia, tienen una enorme ventaja sobre aquellas en quienes el cancer se descubre en una etapa mas avanzada. Muchas pacientes con tumores pequenos son candidatas para reseccion parcial del seno y su pronostico es tan bueno como el de aquellas tratadas con mastectomia. No cabe duda alguna de que una paciente, que ha recibido adecuada educacion sobre el autoexamen de los senos y acude periodicamente a examen medico y mamografico, tiene mejores posibilidades, en el caso de que desarrolle un cancer mamario no solo desde el punto de vista estetico, sono por la supervivencia mas prolongaday mejor calidad de vida

Cancer primario de mama localizado: opciones terapeuticas y pautas para su seleccion / Localized primary breast cancer: therapeutic options and standards for its selection

A medida que nuestros conocimientos sobre la historia natural del cancer mamario han ido en aumento, la mastectomia radical ha venido cediendo lugar a procedimientos quirurgicos que conservan el seno y a una mayor confianza en la radioterapia y la quimioterapia. Probablemente, el factor mas importante en la seleccion del tratamiento es la consulta con un equipo multidisciplinario, con experiencia en los diferentes procedimientos y tecnicas que pueden ser eficaces. La clave para el manejo exitoso es la seleccion de un curso de tratamiento apropiado al cual se pueda adaptar la paciente