Selected radiosurgery cases from the Rotating Gamma Institute Debrecen, Hungary László Bognár M.D., Ph.D., József G. Dobai M.D., Gábor Csiky and Imre Fedorcsák M.D., Ph.D. Department of Neurosurgery, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
Rotating Gamma System-RGS Vertex360 American Radiosurgery Inc., San Diego, CA, USA only 30 individual Co 60 isotope sources The sources rotate along the hemisphere Available secondary collimator sizes: 4, 8, 14, 18 mm Stereotactical frame is required 0,3mm static precision Life-span of the sources is appr. 5 years
481 patients were treated in the period of 8/17/2007-2/23/2009 Avg. 25 patients / month (min 6- max 35) 306 patients were treated in the first year At the beginning, treatment number was less (mainly benign tumors) Nowadays more malignant tumors (metastasis) are treated, and the number of patients is increasing (avg 30-32 /month)
481 patients were treated in the period of 8/17/2007-2/23/2009 Gamma institute is working 2-3 days/ week Patient number is limited by the financing Hungarian National Helath Insurance Fund covers the costs (28 patients/month) We expect 360 treatments in the second year The total capacity is between 500 to 700 cases per year
Distribution of treated patients by the type of pathology (8/17/2007-2/23/2009) Treated Disease No. Pts Metastasis 173 Scwannoma 129 Meningeal tumors 104 Vascular abnormality 42 Pituitiary tumor 11 Primary brain tumors 13 Trigeminal neuralgia 9 Total 481
Treatment duration of treated diseases (minute) Treated disease Average time (min) Max. time Min. time Metastasis 48 276 8 Schwannoma 51 143 10 Meningeal tumors 79 232 11 Vascular abnormality 37 124 10 Pituitary tumor 36 64 10 Glial tumor 48 176 7 Trigeminal neuralgia 47 66 35 Average 49 276 7
Treatment duration will increase by the time because the activity of the Cobalt 60 Isotope decreasing exponentially At time of installation it was 3.6 Gy/min (may, 2007) Currently is 2,88 Gy/min (february, 2009)
Distribution of treated metastases according to the primary site
Distribution of the metastatic neoplasms according to the localization Total metastases 173 Extracranial 1 Intracranial 172 Supratentorial 108 Infratentorial 20 Supra+Infratentorial 32 Basal ggl 12 Unilateral 86 Bilateral 22 Soliter 9 Brain stem + cerebellar 5 2 or more 3 Brain stem 3 Soliter 69 2 or more 17
Extracranial metastasis (epipharynx)
Distribution of Lung Cancer metastatic cases by histology (96 patients)
Before 2 months Contrast enhanced T1W MR images of a lung carcinoma (adenocc.) metastasis before the treatment and 2 months later. The size of the tumor and the edema around it has diminished significantly.
a b Double metastases of a renal cell carcinoma are visible on contrast enhanced CT images prior the treatment (a) and 9 months after (b). After the irradiation, the size of carcinoma is markedly decreased in front and disappeared in the occipital region. The edema around the metastases also diminished.
Multiple metastases of a breast neoplasm are visible before the treatment (upper line) and 3 months after it (down line). Both the size of the tumor and edema decreased.
a b CT image of a metastatic melanoma located on the left side of the precentral region before treatment (a) and 6 months after (b).
Failure 45 yrs old female was treated with a soliter metastatic lesion (21Gy@50%) in the left central region. Previously she was operated on for invasive mamma carcinoma
After treatment initial regression and decreasing of perifocal edema was observed
Failure...but 2 month later a part of tumor started to grow again and edema came back. Two months later patient died due to general dissemination.
Tumor growth control (metastasis) Median margin dose: 14-23 Gy@50% (avg: 19.3Gy) Overall tumor controll rate (no change or regression) 81% Survival time: avg: 6.4 months (increasing) more patients? better selection? RPA.I avg: 8.4 months RPA II avg: 6.7 months RPA III avg: 5.2 months Aim of the treatment : Better quality of life
Treatment of Vesitbular Scwannoma (VS) Experiences of the treatments Results (radiological and clinical)
VS treatment planning Complete coverage of the tumor Preservation of facial, cochlear and trigeminal nerve function For large tumors, preservation of brain stem function is also important Multiisocenter planning combination of small beam diameter collimators (4, 8 mm) Facial nerve along the anterior margin
VS treatment planning Typically prescribed dose: 11-13Gy to the 50% isodose line (generally 12Gy@50%) Low complication rate, high rate of tumor control In case of small target, the dose is prescribed to the 70-80% isodose line
Generally the combination of 4 and 8 mm collimators used, avg. prescribed dose is 12 Gy @ 50% 1 kezelési tervet betenni
Dose plan of a small VS, localised in the internal acustic meatus
Dose plan of a small VS, localized in the internal acoustic meatus
a a b Tipical vestibular schwannoma is observable at the time of treatment on contrast enhanced CT image (a) and 6 months after the treatment on T1- weighted contrast enhanced image (b). The intensity of contrast enhancement is decreased in the middle of the tumor that indicates good reaction for irradiation.
Treatment of previously operated residual or recurrent tumor
Case I 61 yrs old male medical doctor (GP) Right sided hearing loss in the last one year with trigeminal neuralgiform pain in the right V/2 area MR: pontocerebellar tumor (VS) with a 25mm largest diameter
Case I 12Gy @ 50% prescribed dose was used
Case I 6 months after treatment, central loss of contrast enhancement is visible, tumor size unchanged
Case I On the one year control MR images, the tumor size decreased significantly, but the contrast enhancement increased
Case II 72 yrs old female Right sided tinnitus since 4-5years Facial numbness and countinously loss of hearing in the last one year CT, MR: Cystic vestibular schwannoma detected on the right side The tumor was 26mm in the biggest diameter
Case II CT, MR: Cystic vestibular schwannoma detected on the right side The tumor was 26mm in the biggest diameter
Case II Only the solid tumor part was treated with 12 Gy @ 50% prescribed dose
Case II 8 months after treatment, the neurological status unchanged MR shows tumor regression (17mm), cyst disappeared
Follow up by phone. Patient Follow-up Contact with 85 patients from 93. 1 patient died later in lung embolism (independent, not side effect!!) We asked about: Complaints preseted directly after the treatment and complaints presented subsequently. Ability to work. Dynamic of the getting back to work.
Distribution of the presented complaints of the patients during the first 48 hours after the treatment.
Complaints presented in the first 48 hours after the treatment (39 patients with 46 complaints) Complaints after the treatment Patient No Complaints (%) Headache 23 50% Nausea, Vomit 8 17% Vertigo 5 11% Feel fervor 2 4% Brain edema 1 2% Low fever 1 2% Facial hypaesthesia 1 2% Migraine 1 2%
Complaints presented after the first 48 hours of the treatment of VS (25 patients with 28 complaints) Complaints Incidence No Distribution of the complaints Headache 9 32% Vertigo 5 18% Tinnitus 4 14% Transient facial palsy 3 11% Brain edema 2 7% Depression 1 4% Hemispasm 1 4% Memory disturbance 1 4% Epilepsia 1 4% Feeding problems 1 4%
Average time of return to work of patients treated with VS Average 21 days Min.: 1 day Max.: 180 days 44 patients went back to work
The employing distribution of the patients treated with VS Disability Pensioner Working Pensioner Active employee 40 45 Pensioner
Back to work dynamic (n=45) % 54% 85% 97%
Meningioma The goal is to control the growth of the tumor.
CT images of a parasagital meningioma at time of treatment (upper row) and MR pictures of the tumor 8 months after the treatment (lower row). The diminished accumulation of the contrast material in the middle of the tumor shows the effect of the irradiation.
Treatment of trigeminal neuralgia Leksell 1971 35-45 Gy @ 50% isodose
Treatment of trigeminal neuralgia Gasserian ganglion? Historic (Leksell) Root Entry Zone? "American target" Plexus Triangularis? "French target"
Treatment of trigeminal neuralgia Plexus triangularis target Brainstem irradiation dependent of cistern size
Treatment of trigeminal neuralgia Treatment planning of trigeminal nerve irradiation
Treatment of trigeminal neuralgia The pain reduced 6-12 months after the treatment (45Gy@50%).
AVM We treat the nidus, change is observed generally after 2-3 years.
Cavernoma We do not expect any radiological changes, but the frequency of bleedings reduce.
Glioma The treatment of glioma with radiosurgery is controversial, but patients with recurrent, well circumscribed malignant glioma could be good candidates for treatment
Glioma case before after This is a recurrancy after several operations, irradiation and chemotherapy. Histology: Glioblastoma Multiforme Slight regression and necrosis could be achieved with radiosurgery 8 months after treatment. Epileptic seizures has ended, hemiparesis unchanged
Conclusion I. It is not possible to treat every lesion in the brain with Radiosurgery The gamma-radiosurgical treatment, as a non-invasive intervention gives new opportunity beside the conventional open-skull procedures It is not only an alternative treatment, but has become a first line treatment in many diseases Our system has proved to be safe and effective
Conclusion II. The advantages of the concept of a dedicated center are undoubtedly manifested The permanent and skilled employees of the center can guarantee the continuous technical quality control and further development The patient selection and the treatment protocols are under the influence of a multidisciplinary leading group. So each individual case can be optimized, followed up and be comparable to the results of our and other centers
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