Correction: CyberKnife Radiosurgery in Recurrent Brain Metastases: Do the Benefits Outweigh the Risks?

[This corrects the article DOI: 10.7759/cureus.3741.].

Novel Monte Carlo dose calculation algorithm for robotic radiosurgery with multi leaf collimator: Dosimetric evaluation.

PURPOSE: At introduction in 2014, dose calculation for the first MLC on a robotic SRS/SBRT platform was limited to a correction-based Finite-Size Pencil Beam (FSPB) algorithm. We report on the dosimetric accuracy of a novel Monte Carlo (MC) dose calculation algorithm for this MLC, included in the Precision™ treatment planning system. METHODS: A phantom was built of one slab (5.0 cm) of lung-equivalent material (0.09…0.29 g/cc) enclosed by 3.5 cm (above) and 5 cm (below) slabs of solid water (1.045 g/cc). This was irradiated using rectangular (15.4 × 15.4 mm2 to 53.8 × 53.7 mm2) and two irregular MLC-fields. Radiochromic film (EBT3) was positioned perpendicular to the slabs and parallel to the beam. Calculated dose distributions were compared to film measurements using line scans and 2D gamma analysis. RESULTS: Measured and MC calculated percent depth dose curves showed a characteristic dose drop within the low-density region, which was not correctly reproduced by FSPB. Superior average gamma pass rates (2%/1 mm) were found for MC (91.2 ±â€¯1.5%) compared to FSPB (55.4 ±â€¯2.7%). However, MC calculations exhibited localized anomalies at mass density transitions around 0.15 g/cc, which were traced to a simplification in electron transport. Absence of these anomalies was confirmed in a modified build of the MC engine, which increased gamma pass rates to 96.6 ±â€¯1.2%. CONCLUSIONS: The novel MC algorithm greatly improves dosimetric accuracy in heterogeneous tissue, potentially expanding the clinical use of robotic radiosurgery with MLC. In-depth, independent validation is paramount to identify and reduce the residual uncertainties in any software solution.

CyberKnife Radiosurgery in Recurrent Brain Metastases: Do the Benefits Outweigh the Risks?

Introduction Local treatment concepts are in high demand in the salvage treatment of recurrent brain metastases. Still, their risks and benefits are scarcely characterized. In this study, we analyzed the outcome and risk-/benefit-ratio of salvage CyberKnife (Accuray Incorporated, Sunnyvale, California, US) radiosurgery in the treatment of recurrent brain metastases after whole brain radiotherapy (WBRT). Materials and methods Seventy-six patients with 166 recurrent brain metastases and a multimodal pretreatment were retrospectively investigated. All patients underwent salvage CyberKnife radiosurgery (single fraction, reference dose: 17-22 Gy). Study endpoints were post-recurrence survival (PRS) after salvage treatment as well as local and distant tumor control rates. Central nervous system (CNS) toxicity was assessed according to the toxicity criteria of the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC)). Results The population was homogenous regarding its demographic parameters. All patients had a history of WBRT prior to salvage CyberKnife radiosurgery. PRS was 13.3 months (10.4 - 16.2 months), one-year local and distant tumor control rates were 87% (95% CI: 75-99) and 38% (95% CI: 23-52), respectively. Eighteen patients suffered from RTOG/EORTC grade I/II toxicity. No toxicity-related risk factors were identified. Discussion This study found indicative survival and tumor control rates as well as a favorable risk/benefit ratio regarding radiotoxicity in salvage CyberKnife radiosurgery. These results point to a proactive therapeutic strategy based on appropriate patient selection instead of therapeutic nihilism.

Preparation-Dependent Orientation of Crystalline Ice Islands on Ag(111).

We observe the transformation of fractal ice islands grown at 96 K to compact ones annealed at 118 K and compare those to compact islands grown directly at 118 K. The low-temperature grown islands form a four bilayer high wetting layer. The annealing causes a crystallization and reshaping of the islands and a substantial increase in height and roughness in particular at higher coverage. Moreover, it leads to a dewetting of the ice film. The islands grown at the higher temperature show qualitative similarities to the annealed ones at smaller nucleation density. However, their orientation with respect to the surface differs by 30° as compared to the annealed islands.

Robotic Radiosurgery for Adrenal Gland Metastases.

INTRODUCTION: The purpose of this study was to investigate the safety and efficacy of CyberKnife (CK) robotic radiosurgery for treatment of adrenal metastases. METHODS: We performed a retrospective analysis of 23 patients with adrenal metastases who had been treated with CK between October 2006 and December 2015. Fifteen patients received chemotherapy prior to radiosurgery, all patients underwent computer tomography (CT) fluoroscopically guided percutaneous placement of one to three gold fiducials into the adrenal gland. Nineteen patients were selected for single-fraction radiosurgery with a median dose of 22 Gy, four patients were treated in three fractions with a median dose of 13.5 Gy. RESULTS: Median follow-up time was 23.6 months. Four patients (17%) experienced local relapse during the evaluation period with a mean time of 19 months to tumor progression. The actuarial local tumor control rate was 95% after one year and 81% after two years. Three of the four patients with local recurrence were retreated with CK radiosurgery. Dynamic tumor tracking enabled accurate treatment with correlation errors less than 2 mm, despite extensive respiration-induced target motion up to 22 mm. Apart from nausea directly after treatment in five patients, we observed no early or late treatment-related side effects. CONCLUSIONS: Single fraction robotic radiosurgery for adrenal gland metastases is a safe and effective treatment option for patients who are not eligible for surgical resection.

A Novel Method for Quality Assurance of the Cyberknife Iris Variable Aperture Collimator.

OBJECTIVE: To characterize a novel method for field-size quality assurance of a variable approximately circular aperture collimator by means of dose-area product measurements and to validate its practical use over two years of clinical application. METHODS:   To assess methodical limitations, we analyze measurement errors due to change in linac output, beam tuning, uncertainty in MU delivery, daily factors, inherent uncertainty of the large-area parallel-plate ionisation chamber, and misalignment of the large-area parallel-plate ionisation chamber relative to the primary beam axis. To establish a baseline for quality assurance, the dose-area product is measured with the large-area parallel-plate ionisation chamber for all 12 clinical iris apertures in relation to the 60 mm fixed reference aperture. To evaluate the long-term stability of the Iris collimation system, deviation from baseline data is assessed monthly and compared to a priori derived tolerance levels. RESULTS: Only chamber misalignment, variation in output, and uncertainty in MU delivery contribute to a combined error that is estimated at 0.2 % of the nominal field size. This is equivalent to a resolution of 0.005 mm for the 5 mm, and 0.012 mm for the 60 mm field. The method offers ease of use, small measurement time commitment, and is independent of most error sources. Over the observed period, the Iris accuray is within the tolerance levels. CONCLUSIONS:   The method is an advantageous alternative to film quality assurance with a high reliability, short measurement time, and superior accuracy in field-size determination.

Consecutive Mechanism in the Diffusion of D2O on a NaCl(100) Bilayer.

The motion of D2O monomers is investigated on a NaCl(100) bilayer on Ag(111) between 42.3 and 52.3 K by scanning tunneling microscopy. The diffusion distance histogram reveals a squared diffusion lattice that agrees with the primitive unit cell of the (100) surface. From the Arrhenius dependence, we derive the diffusion energy, the pre-exponential factor, and the attempt frequency. The mechanism of the motion is identified by comparison of the experimental results to theoretical calculations. Via low temperature adsorption site determination in connection with density functional theory, we reveal an influence of the metallic support onto the intermediate state of the diffusive motion.

Size dependence of the dispersion relation for the interface state between NaCl(100) and Ag(111).

This study investigates the interface state electron dispersion relation between NaCl(100) islands and Ag(111) dependent upon NaCl island size. Both onset energy and effective mass are size dependent. However, these dependencies are relevant at different island sizes. We trace back this effective mass dependency to a misfit-induced strain based on atomically resolved images. Our results open up new avenues for the development of nanodevices by tuning the effective electron mass via strain of the insulating component.