Single-fraction image-guided robotic radiosurgery efficiently controls local prostate cancer recurrence after radical prostatectomy.

Purpose: To assess the therapeutic potential of single-fraction robotic stereotactic ablative body radiotherapy (SABR) in patients with locally recurrent prostate cancer (PC) after radical prostatectomy (RP). Materials and methods: We included 35 patients with biochemical failure after RP with single-site local recurrence in the prostate bed diagnosed by PSMA PET/CT. About 20/35 pts had previously received post-surgical adjuvant radiation therapy.High-resolution multiparametric magnetic resonance imaging (mpMRI) for exact visualization of tumor tissue was performed at 1.5 (n = 23; Siemens Magnetom Aera) or 3 Tesla (n = 12; Siemens Magnetom VIDA, Siemens Healthineers, Erlangen, Germany). Using the MRI and PET/CT dataset for planning, SABR was carried out after ultrasound-guided placement of a single gold fiducial marker at the site of tumor recurrence using a CyberKnife M6 unit (Accuray Inc., Sunnyvale, USA). Due to the high diagnostic accuracy of PSMA PET/CT and mpMRI, pre-SABR biopsy of tumor tissue was not deemed necessary. PSMA PET/CT performed in median 88 days before SABR confirmed the absence of distant metastases. MpMRI was performed at a median of 22 days prior to the intervention. SABR was performed in a single fraction with a dose of 20 (5/35), 21 (27/35) or 22 (3/35) Gy. Follow-up serum PSA was measured every 3 months thereafter. Results: Median patient age was 72 years (57-80 years) and median time from RP to SABR was 96.8 months (IQR, 69.3-160.2). Median serum PSA before SABR was 1.38 ng/mL (IQR 0.75-2.72). At 3 months, median PSA had dropped significantly in 27/35 patients to a median of 0.35 ng/mL (IQR 0.25-0.68). At 6 months, 30/35 patients showed biochemical response to SABR, while five patients were progressing: three had systemic disease on PSMA PET/CT, while two patients had rising PSA values without a visible correlate on PET/CT. The median follow-up time was 16 months. Grade 1 genitourinary (GU) toxicity was reported in 3/35 patients (9%) and grade 1 gastrointestinal (GI) toxicity in 2/35 patients (6%), respectively. Conclusion: SABR is an efficient new treatment option in the management of single-site local recurrent PC without the evidence of systemic disease; due to its very low toxicity, it is an alternative to surgical re-treatment or other focal therapies. It can significantly delay the onset of androgen deprivation therapy (ADT) in biochemical failure after radical prostatectomy.

Quality of life in the follow-up of uveal melanoma patients after enucleation in comparison to CyberKnife treatment.

PURPOSE: To compare quality of life (QoL) in patients with uveal melanoma after enucleation and stereotactic radiosurgery to that in an age-matched patient collective. METHODS: QoL was assessed in a cross-sectional survey and compared among 32 uveal melanoma patients after enucleation, 48 patients after stereotactic radiosurgery (CyberKnife(®); Accuray(®) Incorporated, Sunnyvale, CA, USA), and an age-matched control group of 35 patients, using the SF-12 Health Survey. Statistical analysis was performed with Fisher's exact test, Student's t test, one-way ANOVA analysis, Wilcoxon rank-sum (Mann-Whitney test), and ordered logistic regression for multivariate analysis. RESULTS: There was no significant difference in QoL between patients treated by stereotactic radiosurgery and the age-matched control group. After enucleation, patients presented significantly lower values in Physical Functioning (PF), Role Physical (RP), and Role Emotional (RE) compared to the radiosurgery and control group. To control for the overall QoL lowering effect of visual loss, the QoL of the patients who underwent enucleation was compared with the QoL of patients suffering severe functional loss after CyberKnife radiosurgery in a subgroup analysis, which showed no statistically significant difference. The number of comorbidities had a significant impact on QoL in multivariate analysis. CONCLUSIONS: Superior performance in PF, RP, and RE suggests that CyberKnife represents a suitable first-line therapy for uveal melanoma. In cases with painful amaurosis or vast tumor recurrence, enucleation can be performed with an acceptable QoL outcome.

CyberKnife radiosurgery for the treatment of orbital metastases.

Purpose of this study is to evaluate radiographic therapy response, clinical outcome and adverse effects of CyberKnife radiosurgery in patients suffering from orbital metastases. Sixteen orbital metastases originating from different solid cancers in fourteen patients were treated by single fraction CyberKnife radiosurgery. Radiographic response and clinical outcome were evaluated. The treated tumor volume ranged from 0.2 to 35 cm3 (median 2.3 cm3, mean 7.0 cm3, SD 6 10.4 cm3, CI 0.9-9.4 cm3). The prescription dose ranged from 16.5-21 Gy (median 18 Gy, mean 18.2 Gy, SD 6 1.2 Gy, CI 17.0-18.4 Gy). A no change situation was observed in nine lesions, partial remission in four as well as complete remission in one metastasis. Tumor growth was stabilized or regressive following CyberKnife therapy in 87% of the cases. Recurrence was observed in two cases (13%). Before therapy, three patients suffered from visual disturbance and five patients reported diplopia. Six patients had no initial symptoms. After therapy, one patient indicated improvement of the present visual deficit and two patients no change. Out of the two patients with persistent diplopia, two reported improvement after therapy and three no change. No progression of symptoms was noted in any of the cases. Fourteen out of sixteen treated lesions were stable or regressive following CyberKnife radiosurgery (87%). As no serious adverse effects were reported in this series, CyberKnife therapy was shown to be of great value for local management of orbital metastases.

Radiosurgery of spinal meningiomas and schwannomas.

Purpose of this study is to analyze local control, clinical symptoms and toxicity after image-guided radiosurgery of spinal meningiomas and schwannomas. Standard treatment of benign spinal lesions is microsurgical resection. While a few publications have reported about radiosurgery for benign spinal lesions, this is the first study analyzing the outcome of robotic radiosurgery for benign spinal tumors, treated exclusively with a non-invasive, fiducial free, single-fraction setup. Thirty-six patients with spinal meningiomas or schwannomas were treated, utilizing a robotic radiosurgery system (CyberKnife®, Accuray Inc. Sunnyvale CA), and were followed prospectively. Medical history, histology, clinical symptoms and radiographic outcome were recorded. Thirty-nine spinal lesions were treated because of tumor recurrence, remnants after microsurgery, multiple lesions, or rejection of open surgery. Median age was 45 years (range 18-80 years). Median target volume was 3.4 cm(3) (range 0.2-43.4 cm(3)). Histology revealed 28 schwannomas and 11 meningiomas (WHO grade I). All spinal levels were affected. Median prescription dose was 14 Gray (95% C.I. 13.4-14 Gy) to the 70% isodose. After a median follow-up of 18 months (range 6-50 months) no local tumor progression was detected. 20 lesions (51%) remained stable, 19 tumors (49%) decreased in size. One patient with schwannomatosis was treated repeatedly for three new tumor locations. Pain was the initial symptom in 16 of 25 schwannoma patients, and in 3 of 11 patients with meningiomas. Pain levels decreased in 8/19 patients. All but one patient with motor deficits remained clinically stable. No myelopathic signs where found. Single-session radiosurgery for benign spinal tumors in selected patients has proven to inhibit tumor progression within the observed period without signs of early toxicity. Radiosurgery offers an additional treatment option, if microsurgery is not feasible in cases of tumor recurrence, post-resection remnants, multiple lesions, or medical comorbidity.

Combined surgical and radiosurgical treatment of symptomatic aggressive vertebral osteomyelitis.

INTRODUCTION: The surgical treatment of vertebral osteomyelitis can be complicated by severe additional diseases or the need for extensive debridement with concomitant risks. We report a case of combined surgical and radiosurgical treatment of idiopathic vertebral osteomyelitis of L4. CASE REPORT: The patient presented with progressive enlargement of the right side of the vertebral body L4 due to chronic fibrous osteomyelitis without evidence of infection, leading to compression of nerve roots L4, L5 and the dural sac with resulting radicular paresis. During decompression of the nerve roots via a dorsal approach, massive bleeding from the inflammatory vertebral body occurred, making abortion of surgery necessary. Remnant inflammatory masses of vertebral body L4 were treated by spinal robotic radiosurgery with a high tumoricidal dose of 20 Gy without clinical and radiological signs of relapse of disease in the following three years. CONCLUSION: We describe a case of the combined surgical and radiosurgical treatment of lumbar osteomyelitis with symptomatic nerve root compression. Dorsal decompression followed by spinal radiosurgery for the anterior vertebral parts with avoidance of potentially dangerous anterior spondylectomy led to a rapid improvement of paresis and pain with persistent control of vertebral inflammation and enlargement. The described case of close cooperation of surgeons and radiosurgeons offered an effective and functionality preserving treatment in this challenging case.

[Cyberknife surgery with a radio-scalpel: a new treatment option for patients with unresectable metastases]. / Cyberknife-Chirurgie mit dem Strahlenmesser: eine neue Behandlungsalternative für Patienten mit inoperablen Metastasen.

Patients with non-resectable metastases of various diseases are today treated by one of several different techniques, such as radiofrequency ablation, laser-induced thermoablation or stereotactic radiotherapy. Frequently, the employment of these therapeutic strategies is limited due to their invasiveness and treatment-associated morbidity. Furthermore, stereotactic radiotherapy is associated with a high degree of patient discomfort due to the necessary fixation of moving inner organs (lung, liver). With the development of the cyberknife radiosurgery technique, an image-guided, superselective, robot-based radiotherapy, these problems seem to be resolved. With this technique, metastases may be treated in an outpatient single-treatment setting.

Frameless single-session robotic radiosurgery of liver metastases in colorectal cancer patients.

INTRODUCTION: Due to advanced chemotherapy regimens, patients presenting with residual liver metastases of colorectal cancer (CRC) has increased. Surgery of residual metastases enhances overall survival, but surgical resection is often limited. Less invasive techniques have been invented to enhance local disease control. We investigated in a selected patient cohort local control of liver metastasis from CRC using robotic radiosurgery. METHODS AND MATERIALS: In this study patients with colorectal liver metastases were prospectively followed after having been treated with single-session radiosurgery using a robotic image-guided device and real-time tumour tracking. The primary end-point was local control (LC); secondary end-points were toxicity, progression-free survival (PFS) and overall survival (OS). Extrahepatic metastases were excluded using a whole body (PET-CT: positron emission tomography computed tomography). Follow up was done by liver MRI every 3 months post-treatment. RESULTS: Fourteen patients (median age 65 years), with a total of 19 colorectal liver metastases were treated with 24 Gy in one fraction. Median follow up was 16.8 months. A one-year LC rate of 87% and a median PFS of 9.2 months were reached. DISCUSSION: Frameless robotic image-guided radiosurgery with real-time tumour tracking as an effective treatment for patients with colorectal liver metastases. This technique enhances the possibilities of multidisciplinary oncological concepts.

[Interventional oncology for lung tumors]. / Interventionelle Onkologie bei Lungentumoren.

Lung tumors and pulmonary metastases together are the most common cause of cancer-related death in men and the second most frequent in women. Up to now, surgical resection has remained the gold standard in the treatment of pulmonary tumors, being the only treatment option that was potentially curative and offered the possibility of a significant increase in life expectancy after successful therapy. Over the past decade, percutaneous radiofrequency ablation (RFA) has gained worldwide acceptance in the treatment of primary and secondary tumors of the liver with curative intent, so that indications for RFA have been extended to embrace tumors in other organs, e.g. the lung. Since the first case results were described, the number of publications dealing with the treatment of lung tumors using thermal ablative therapies has increased significantly. The aims of the present article are to give a short overview of emerging therapies such as cyberknife surgery and also, especially, to describe the indications for and technique of RFA, to discuss the ideal method of follow-up, and to highlight possible complications of the therapy and the current results of RFA of primary and secondary lung tumors. In addition, the value of combining RFA with other therapy modes (especially chemotherapy and radiation therapy)is briefly treated.

Technical description, phantom accuracy, and clinical feasibility for single-session lung radiosurgery using robotic image-guided real-time respiratory tumor tracking.

To describe the technological background, the accuracy, and clinical feasibility for single session lung radiosurgery using a real-time robotic system with respiratory tracking. The latest version of image-guided real-time respiratory tracking software (Synchrony, Accuray Incorporated, Sunnyvale, CA) was applied and is described. Accuracy measurements were performed using a newly designed moving phantom model. We treated 15 patients with 19 lung tumors with robotic radiosurgery (CyberKnife, Accuray) using the same treatment parameters for all patients. Ten patients had primary tumors and five had metastatic tumors. All patients underwent computed tomography-guided percutaneous placement of one fiducial directly into the tumor, and were all treated with single session radiosurgery to a dose of 24 Gy. Follow up CT scanning was performed every two months. All patients could be treated with the automated robotic technique. The respiratory tracking error was less than 1 mm and the overall shape of the dose profile was not affected by target motion and/or phase shift between fiducial and optical marker motion. Two patients required a chest tube insertion after fiducial implantation because of pneumothorax. One patient experienced nausea after treatment. No other short-term adverse reactions were found. One patient showed imaging signs of pneumonitis without a clinical correlation. Single-session radiosurgery for lung tumor tracking using the described technology is a stable, safe, and feasible concept for respiratory tracking of tumors during robotic lung radiosurgery in selected patients. Longer follow-up is needed for definitive clinical results.