Gamma Knife Radiosurgery A Team Approach to Treating Patients George Bovis, MD Patrick Sweeney, MD Jagan Venkatesan, MS Matt White, MS Illinois Gamma Knife Center Elk Grove Village, IL
Disclosures Shareholders in IGKC
Purpose Define Stereotactic Radiosurgery Discuss specifics of Gamma Knife radiosurgery- 4c/Perfexion Review clinical indications and our experience at the Illinois Gamma Knife Center Discuss competing indications for GKRS (Proton Beam Therapy)
Stereotactic Radiosurgery SINGLE FRACTION High dose Small volume High conformality Excludes sensitive structures Exclusively CRANIAL Exclusively FRAME- BASED OLD SCHOOL DEFINITION
Stereotactic Radiation: 2014 SABR (stereotactic ablative body RT) SBRT (stereotactic body radiotherapy SRT (stereotactic radiotherapy) SRS (stereotactic radiosurgery)
1980s 1990s 2000s 2010s adiation herapy 2-d 3-d CRT IMRT IGRT Stereotactic Radiosurgery Frame based Frame based Relocatable frames Gamma U series Exclusively CRANIAL Frameless CRANIAL, SPINE, LUNG, PROSTATE, LIVER, PANCREAS Linac based
We are all radiosurgeons now! Varian True Beam
Gamma Knife Lars Leksell Swedish Neurosurgeon First developed Gamma Knife in 1968 Was a neurosurgical device that used radiation
Stereotaxy Implies defining a point in space relative to a Cartesian coordinate system: FRAME There are surgical instruments that use stereotaxis to locate targets in the body In radiation therapy simulation and treatment we also use stereotaxis but it is relative to a CT-generated image: PATIENT
Gamma Knife Radiosurgery Only exclusively frame-based intracranial system that is still used today All other radiosurgery systems are capable of frameless and extracranial indications
The Leksell Patient frame vs
The Leksell Frame placement and Coordinate System
History 1951 Lars Leksell Large Number of Converging Beams of Ionizing Radiation Creating Small Volumes of Necrosis at Stereotactically Targeted Region of Brain
History LINAC Gamma Radiation Protons Stereotaxis Target Visualization X-Ray Pneuomoencephalography Angiography
History Cobalt-60 Unit 1967 Gamma Knife 179 Co-60 Sources Sophiahemmet Hospital 1974 Gamma Knife U Unit 201 Co-60 Sources Karolinska Hospital
History 1970-1987 CT MRI Improved Stereotaxis with Computers Better Understanding of Radiobiology
History 1968 1982 Treated 762 patients Trigeminal Neuralgia Acoustic Neuroma AVM Pituitary Adenoma Meningioma Metastasis Functional
History 1987 - First Gamma Knife installed in U.S., at the University of Pittsburgh Lunsford 1989 Mayo Clinic Coffey Formalized And Methodical Study of GK SRS Publication of Huge Body of Scientific Work
Evolution Cobalt-60 201 Sources Leksell Frame Trunnion Mode Collimator Size 4 mm, 8 mm, 14 mm, 18 mm Manually Mounted
Evolution Computer Based Workstations Planning Software 3D Dosimetry and Anatomical Imaging Improved Conformality and Selectivity Robotic Automatic Positioning System (APS)
Evolution
Evolution 2002 Elekta Next Generation of GK 2 Principles Would Not Change Converging Beams Frame Goals For New Machine Best Dosimetry Best Radiation Protection Unlimited Cranial Reach Fully Robotic and Automated Outstanding Patient Comfort Ease of Treatment For Pt and Staff Maintain Relevance of Cumulative Worldwide Literature
The Anatomy of the Gamma Knife 4C 1 - Couch Support 2 - Patient Couch 3 - Helmet 4 - Shielding Door 5 - Beam Channel 6 - Cobalt-60 Sources 7 - Shielding 8 - Helmet In Treatment Position 9 - Sliding Cradle
The Perfexion
The Perfexion System
The Perfexion Couch
PerfeXion Shielding
Not Good Protection or Shielding
PerfeXion Jean Regis, et al Radiosurgery With The World s First Fully Robotized Leksell Gamma Knife PerfeXion in Clinical Use: A 200- Patient Prospective, Randomized, Controlled Comparison With The GK 4C. Neurosurgery 64 (2), Feb 2009 33 % Reduction in Tx Time 30 % Reduction in Shots Used Nearly All Cases Single Run No Collisions 8.2 X Less XRT To Vertex 13 X Less XRT To Sternum 15 X Less XRT To Gonads
PerfeXion STILL A Growth Area in Neurosurgery WBRT vs SRS/GK for Multiple Mets (#?) Kalkanis, S, et al. Evidence-based clinical practice parameter guidelines for the treatment of patiens with metastatic brain tumors. J Neurooncology (2010) 96: 7-10. Robinson, P, et al. Methodology used to develop the AANS/CNS management of brain metastases evidencebased clinical practice parameter guidelines. J Neurooncology (2010) 96: 11-16. Gaspar, L, et al. The whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncology (2010) 96: 17-32. Kalkanis, S, et al. The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncology (2010) 96: 33-43. Epilepsy (MTLE) NIH Study Radiosurgery or Open Surgery for Epilepsy (ROSE), PI Nicholas Barbaro Cluster Headache Kano, K, et al. Stereotactic radiosurgery for intractable cluster headache: an initial report from the North American Gamma Knife Consortium. J Neurosurgery. April 30, 2010 DBS vs SRS/GK for OCD, Depression
PerfeXion Gamma Knife Comes With Patients Direct Patient Requests Gold Standard Exercise In Efficiency More Options For Your Patients Complete Brain Surgeon
A Pinpoint Beam Strays Invisibly, Harming Instead of Healing By Walt Bogdanich and Kristina Rebelo December 28, 2010
http://www.nytimes.com/2010/12/29/he alth/29radiation.html?_r=1
PerfeXion Illinois Gamma Knife Center 2005 2 Neurosurgeons 2 Radiation Oncologists 2014 8 Neurosurgeons 4 Radiation Oncologists
Gamma Knife: Dosimetry SHOTS: spheres of dose Pack shots into irregular shaped targets MRI/CT/Angio Rarely contour Never add a margin Prescribe to 50% isodose line Not concerned about inhomogeneity in the target MD/PD: maximum dose/rx dose Very concerned about conformality: CI: volume of Rx isodose/ volume of target volume at Rx isodose level Cleveland Clinic
Linac-based SRS Circular collimators mmlc Dynamic arcs IMRT Contour Small margin Homogenous dose distribution
Gamma Knife Radiosurgery Target Isodose lines
Gamma: Knife: A Team Approach
Gamma Knife Process Outpatient One day Imaging Planning Treatment Treat to 7 pts/day Stand-alone clinic: plan and treat patients/ consults/follow-ups
The four basic steps on Tx Day 1. Head Frame Placement 2. Imagin g 3. Treatment planning 4. The Treatment
Gamma Knife Advantages A Neurosurgeon s perspective Lower Risks Compared to Open Surgery Better Tolerared than Open Surgery Outpatient No Recovery Time Return to work in 1 day Very Accurate and Precise Treatment for previously inoperable brain tumors. Simple Procedure (when performed correctly) A Fool With A Tool, Is Still a Fool Pain-Free Gamma Knife treatment usually more cost-effective than Open Surgery.
Clinical Indications Brain Metastasis Meningiomas Vestibular Schwannomas Trigeminal Neuralgia Arteriovenous Malformations Gliomas Skull-Base Tumors Pituitary Tumors Other functional disorders OCD, Epilepsy, Tremors
Our Experience
Most Common Indication Ideal targets Round Non-infiltrating Easily Defined Most common Tumor Types Breast Lung Melanoma Renal Colon Brain Metastasis
Whole Brain RT becoming more controversial Especially in solitary metastasis What is the maximum number of metastasis to treat? 5 10 15.. Brain Metastasis
53 yo female with multiple brain metastasis. Refused WBRT
Mets Plan 1 (6 Months)
Mets Plan 2 (3 & 6 Months)
Arteriovenous Malformations (AVM) Abnormal collection of blood vessels bypassing the capillary system Can occur in any part of the body Symptoms are headache/seizures
Arteriovenous Malformations (AVM) Natural History 2-4 % Rate of Rupture per Year 10-20 % Mortality per Rupture 30-50 % Major Neurological Morbidity per Rupture Likelihood of rupture in lifetime 105 Age in Years New Data: Lancet, 383: 614-621, 2014 ARUBA TRIAL (A randomised trial of unruptured brain AVM) Randomized patients with unruptured AVMs to medical mgmt alone versus some intervention (surgery, embolization, SRS, combinations) Medical management alone is superior to interventional therapy in the prevention of death or stroke 10% in medical mgmt had death or stroke vs. 30.7% in the intervention arm
AVM visualized on MRI
AVM with Angio & MRI
3D Model of the AVM
AVM Case 1 Presentation @ Initial Consult 2 Years Post Gamma Knife
AVM Case 2 Presentation 4 Years Post GK
AVM Case 3 Presentation 1 Year Post GK
Tumors that arise from the meninges 90-95% are benign Many are asymptomatic and require no intervention Surgery is primary treatment SRS is reasonable for small, unresectable meningiomas Meningioma
Meningioma Plan (1.5 Years)
Trigeminal Neuralgia (TN) Lancinating Pain in distribution of CN V Unilateral Relieved by medication Normal exam triggers Treatments: MVD, PSR, GKRS
TN Plan
Vestibular Schwannoma Acoustic neuroma Benign tumor of the vestibulochochlear nerve (CN 8) 3000 per year in US Treatment options: observation Surgery SRS (GKRS) fsrt conventional RT SRS has become prime treatment for these tumors
Microsurgery Results Best Current Results Published By High Volume Surgeons (Tumors < 3 cm) High Rate of Complete Rsxn Low Recurrence Rate High Rate of Normal / Near Normal CN 7 Function 85% Hearing Preservation??? Depends on approach and Pre-Operative Hearing 12-80% Chance of Deafness / Hearing Loss Kaylie DM, Horgan MJ, Delashaw JB, McMenomey SO: A Meta-Analysis comparing outcomes of microsurgery and gamma knife radiosurgery. Laryngoscope 110:1850-1856, 2000. Pollock BE, Lunsford LD, Noren G: Vestibular-schwannoma management in the next century: a radiosurgical perspective. Neurosurgery 43:475-483 Sekhar LN, Gormley WB, Wright DC: The best treatment for vestibular schwannoma (acoustic neuroma): Microsurgery or radiosurgery? A J Otol 17:676-682, 1996
Gamma Knife Radiosurgery Frame Application MRI with Gad Planning Treatment
Gamma Knife Radiosurgery Advantages Single Morning Session, Outpatient Treatment No Recovery No Post-Treatment Restrictions Very Well Tolerated Highly Successful Tumor Control 98% Facial Nerve Function Preserving 99% Hearing Preservation 60-80%
Gamma Knife Radiosurgery Disadvantages / Risks Tumor is still there! Adverse Radiation Effects 2% Malignant Transformation 1 / 1,000 Infection 1 / 4,000 2 % Failure Rate Requiring Further Treatment 6 month 3 years Latency of Response
Gamma Knife Radiosurgery 12-13 Gy to 50% Isodose Maximal Dose 24-26 Gy Keeping Median Cochlear Dose < 4 Gy Increases Chance of Hearing Preservation Average: 12-15 Isocenters, Using 4mm, 8mm Collimators
Gamma Knife Radiosurgery RESULTS Pollock BE, Driscoll CLW, Foote RL, Link MJ. Patient Outcomes After Vestibular Schwannoma Management: A Prospective Comparison of Microsurgical Resection and Stereotactic Radiosurgery. Neurosurgery 59 (1) July 2006: 77-85. Prospective Cohort Study of 82 Pts All Tumors < 3 cm 82 Patients 46 GK SRS 36 Microsurgery
Gamma Knife Radiosurgery RESULTS Pollock BE, Driscoll CLW, Foote RL, Link MJ. Patient Outcomes After Vestibular Schwannoma Management: A Prospective Comparison of Microsurgical Resection and Stereotactic Radiosurgery. Neurosurgery 59 (1) July 2006: 77-85. CN 7 Fx CN 7 Fx CN 7 Fx CN 8 Fx CN 8 Fx CN 8 Fx 3 mo 1 yr Last 3 mo 1 yr Last GK SRS Micro- Surgery 100 100 96 77 63 63 61 69 75 5 5 5
Gamma Knife Radiosurgery RESULTS Presentation 12 Months Post GK
Gamma Knife Radiosurgery RESULTS Presentation 6 Months post GK 2 Years post GK
Gamma Knife Radiosurgery RESULTS GK 6mo 9mo 12mo 24mo
Acoustic Neuromas A Radiosurgical Perspective of the Future Microsurgery GK Radiosurgery 2000 1500 1000 500 0 1987 1990 1993 1996 1999 2002 2005 2010 2020
Vestibular Schwannomas GK SRS is very safe and effective treatment for Acoustic Neuromas GK SRS compares favorably to Microsurgery for Preservation CN 7 and CN 8 Functions GK SRS is Best for Tumors < 3 cm
GK for OCD?!? 90 Gy to 50% isodose line (180 Gy) Target is anterior limb of internal capsule 4 shots in both right and left hemisphere EXPERIMENTAL
Obsessive Compulsive Disorder (OCD)
3D Model of an OCD Tx
Pituitary tumors Keep the optic apparatus dose below 8 Gy with single fraction If the tumor is abutting or too close to the optic apparatus- not a candidate for Gamma Knife Small/ functional tumors > 5 mm from optic apparatus are excellent candidates for Gamma Knife Macroadenomas/ Nonfunctional pituitary tumors: PBT or GK
Pituitary Plan
Protons vs. GKRS
First Principles: Gamma Knife Intracranial Above the foremen magnum < 3 cm Clearly imaged Away from critical structures (optic apparatus) PBT Adherent to or close to critical structures Large (> 3cm) Ill-defined lower skull base
Cavernous sinus meningioma
Glomus vagale tumor
What about protons? Brain metastasis AVMs Vestibular schwannoma Trigeminal neuralgia Pituitary tumors Meningioma Large/involving optic apparatus Small/peripheral NO NO NO (probably) NO YES YES NO