Dosimetric Plan Comparison of Accelerated Partial Breast Irradiation (APBI) Using CyberKnife

Lee, Chang Yeol,Kim, Woo Chul,Kim, Hun Jeong,Lee, Jeongshim,Park, Seungwoo,Huh, Hyun Do Korean Society of Medical Physics 2018 의학물리 Vol.29 No.2

Accelerated partial breast irradiation (APBI) is a new treatment delivery technique that decreases overall treatment time by using higher fractional doses than conventional fractionation. Here, a quantitative analysis study of CyberKnife-based APBI was performed on 10 patients with left-sided breast cancer who had already finished conventional treatment at the Inha University Hospital. Dosimetric parameters for four kinds of treatment plans (3D-CRT, IMRT, VMAT, and CyberKnife) were analyzed and compared with constraints in the NSABP B39/RTOG 0413 protocol and a published CyberKnife-based APBI study. For the 10 patients recruited in this study, all the dosimetric parameters, including target coverage and doses to normal structures, met the NSABP B39/RTOG 0413 protocol. Compared with other treatment plans, a more conformal dose to the target and better dose sparing of critical structures were observed in CyberKnife plans. Accelerated partial breast irradiation via CyberKnife is a suitable treatment delivery technique for partial breast irradiation and offers improvements over external beam APBI techniques.

Clinical Results of $Cyberknife^{(R)}$ Radiosurgery for Spinal Metastases

Chang, Ung-Kyu,Youn, Sang-Min,Park, Sukh-Que,Rhee, Chang-Hun The Korean Neurosurgical Society 2009 Journal of Korean neurosurgical society Vol.46 No.6

Objective : Primary treatment of spinal metastasis has been external beam radiotherapy. Recent advance of technology enables radiosurgery to be extended to extracranial lesions. The purpose of this study was to determine the clinical effectiveness and safety of stereotactic radiosurgery using Cyberknife in spinal metastasis. Methods : From June, 2002 to December, 2007, 129 patients with 167 spinal metastases were treated with Cyberknife. Most of the patients (94%) presented with pain and nine patients suffered from motor deficits. Twelve patients were asymptomatic. Fifty-three patients (32%) had previous radiation therapy. Using Cyberknife, 16-39 Gy in 1-5 fractions were delivered to spinal metastatic lesions. Radiation dose was not different regarding the tumor pathology or tumor volume. Results : After six months follow-up, patient evaluation was possible in 108 lesions. Among them, significant pain relief was seen in 98 lesions (91%). Radiological data were obtained in 83 lesions. The mass size was decreased or stable in 75 lesions and increased in eight lesions. Radiological control failure cases were hepatocellular carcinoma (5 cases), lung cancer (1 case), breast cancer (1 case) and renal cell carcinoma (1 case). Treatment-related radiation injury was not detected. Conclusion : Cyberknife radiosurgery is clinically effective and safe for spinal metastases. It is true even in previously irradiated patients. Compared to conventional radiation therapy, Cyberknife shows higher pain control rate and its treatment process is more convenient for patients. Thus, it can be regarded as a primary treatment modality for spinal metastases.

로봇사이버나이프를 이용한 간 종양의 실시간 움직임 측정과 방사선수술 시 호흡추적장치의 정확성 평가

김가중(Gha jung Kim),심수정(Su Jung Shim),김정호(Jeong Ho Kim),민철기(Chul Kee Min),정원규(Weon-kuu Chung) 대한방사선종양학회 2008 Radiation Oncology Journal Vol.26 No.4

목 적: 본 연구에서는 로봇 사이버나이프의 호흡추적장치(SynchronyTM Respiratory motion tracking system)을 이용 하여 방사선수술을 시행한 간 종양환자를 대상으로 치료 중 실시간 종양의 움직임을 정량적으로 측정하고 방사선 수술시 호흡추적장치의 정확성을 평가하고자 한다. 대상 및 방법: 사이버나이프 치료를 시행한 간 종양 환자 24명을 대상으로 호흡추적 장치를 이용하여 총 64회의 시술을 시행하였다. 모든 환자에서 초음파를 이용하여 간 종양 근처에 4∼6개의 금침을 삽입하였고 치료계획용 컴퓨터 단층촬영 영상을 이용하여 치료계획을 세웠다. 매 치료 시 금침의 위치는 치료계획 시 만들어진 디지털 재구성 방사선 영상(Digitally Reconstructed Radiography; DRR)과 실시간으로 촬영되어진 방사선영상(X-ray Image)으로 확인하고, 이 결과를 MTS (Motion Tracking System)을 통해 Mtsmain.log 치료파일 형식으로 저장하여 종양의 움직임을 측정하였다. 또한 사이버나이프를 이용한 방사선 수술 시 호흡추적장치의 정확성은 실시간 금침의 위치와 미리 예측된 좌표 사이의 상관관계 오차(Correlation Error)로 평가하였다. 결 과: 간 종양의 직선형태 움직임은 SI (Superior-Inferior)방향으로 최대 23.5 mm, 평균 13.9±5.5 mm, LR (Left-Right)방향으로 최대 3.9 mm, 평균 1.9±0.9 mm, AP (Anterior-Posterior)방향으로 최대 8.3 mm, 평균 4.9 ± 1.9 mm 였으며 간 종양의 회전 운동 정도는 X (Left-Right)축 회전은 최대 3.3o, 평균 2.6±1.3o, Y (Cranio-Caudal)축회전은 최대 4.8o, 평균 2.3±1.0o, Z (Anterior-Posterior)축 회전은 최대 3.9o, 평균 2.8±1.1o로 측정되었다. 또한 치료의 정확성을 평가하는 상관관계 오차는 평균 1.1±0.7 mm였다. 결 론: 본 연구에서 방사선 수술 중 간 종양의 실시간 움직임을 정량적으로 확인할 수 있었고 로봇 사이버나이프의 호흡추적 장치를 이용한 방사선 수술의 정확성을 평가할 수 있었다. 이를 토대로 간 종양의 방사선 수술이나 일반적인 방사선치료에 있어서 치료용적의 결정과 움직임에 대한 유용한 정보를 제공할 것이라 생각된다. Purpose: This study aimed to quantitatively measure the movement of tumors in real-time and evaluate the treatment accuracy, during the treatment of a liver tumor patient, who underwent radiosurgery with a Synchrony Respiratory motion tracking system of a robot CyberKnife. Materials and Methods: The study subjects included 24 liver tumor patients who underwent CyberKnife treatment, which included 64 times of treatment with the Synchrony Respiratory motion tracking system (SynchronyTM). The treatment involved inserting 4 to 6 acupuncture needles into the vicinity of the liver tumor in all the patients using ultrasonography as a guide. A treatment plan was set up using the CT images for treatment planning uses. The position of the acupuncture needle was identified for every treatment time by Digitally Reconstructed Radiography (DRR) prepared at the time of treatment planning and X-ray images photographed in real-time. Subsequent results were stored through a Motion Tracking System (MTS) using the Mtsmain.log treatment file. In this way, movement of the tumor was measured. Besides, the accuracy of radiosurgery using CyberKnife was evaluated by the correlation errors between the real-time positions of the acupuncture needles and the predicted coordinates. Results: The maximum and the average translational movement of the liver tumor were measured 23.5 mm and 13.9±5.5 mm, respectively from the superior to the inferior direction, 3.9 mm and 1.9±0.9 mm, respectively from left to right, and 8.3 mm and 4.9±1.9 mm, respectively from the anterior to the posterior direction. The maximum and the average rotational movement of the liver tumor were measured to be 3.3o and 2.6±1.3o, respectively for X (Left-Right) axis rotation, 4.8o and 2.3±1.0o, respectively for Y (Cranio-Caudal) axis rotation, 3.9o and 2.8±1.1o, respectively for Z (Anterior-Posterior) axis rotation. In addition, the average correlation error, which represents the treatment’s accuracy was 1.1±0.7 mm. Conclusion: In this study real-time movement of a liver tumor during the radiosurgery could be verified quantitatively and the accuracy of the radiosurgery with the Synchrony Respiratory motion tracking system of robot could be evaluated. On this basis, the decision of treatment volume in radiosurgery or conventional radiotherapy and useful information on the movement of liver tumor are supposed to be provided.

Successful Treatment of Infantile Fibrosarcoma Spinal Metastasis by Chemotherapy and Stereotactic Hypofractionated Radiotherapy

Lo, Cheng-Hsiang,Cheng, Shin-Nan,Lin, Kuen-Tze,Jen, Yee-Min The Korean Neurosurgical Society 2013 Journal of Korean neurosurgical society Vol.54 No.6

We report a case of infantile fibrosarcoma in an 8-month-old boy manifested as a right-sided lower leg mass. Repeated local recurrence and distant metastasis were noted during the following three-year period. Whole body fluoro-deoxyglucose positron emission tomography scan revealed an asymptomatic metastasis involving the fourth lumbar vertebrae. The patient received chemotherapy (VAC regimen) with Cyberknife$^{(R)}$ stereotactic hypofractionated radiotherapy (26 Gy; 4 fractions). This treatment reduced tumor size by 23% without acute radiation toxicity even after 33 months. This case suggests that combining chemotherapy and this form of radiotherapy may be safe and effective against childhood spinal metastasis.

A Fusion Study on the Selection of Cyberknife Technique according to the Location of the Pulmonary Tumors

김갑중,김정호,배석환,김낙상,서선열 한국융합학회 2019 한국융합학회논문지 Vol.10 No.7

Depending on the location of the lung tumor, the choice of treatment technique should be considered when treating the Cyberknife. The 4DCT images of 18 lung cancer patients were analyzed, and location error values were extracted through application program. The evaluation result was lower than the average position error only in the upper and the inner. These results suggest that the Vertebral tracking technique is effective when it is close to the pulmonary attachment or near the vertebral body, and the Synchrony technique is effective at other positions. In the future, we would like to study cyber knife treatment technique according to the position of the tumor as well as the volume of the lung and the respiratory cycle.

Prognostic Factors in Patients with Non-small Cell Lung Carcinoma and Brain Metastases: a Malaysian Perspective

Tang, Weng Heng,Alip, Adlinda,Saad, Marniza,Phua, Vincent Chee Ee,Chandran, Hari,Tan, Yi Hang,Tan, Yan Yin,Kua, Voon Fong,Wahid, Mohamed Ibrahim,Tho, Lye Mun Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.5

Background: Brain metastases occur in about 20-40% of patients with non-small-cell lung carcinoma (NSCLC), and are usually associated with a poor outcome. Whole brain radiotherapy (WBRT) is widely used but increasingly, more aggressive local treatments such as surgery or stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) are being employed. In our study we aimed to describe the various factors affecting outcomes in NSCLC patients receiving local therapy for brain metastases. Materials and Methods: The case records of 125 patients with NSCLC and brain metastases consecutively treated with radiotherapy at two tertiary centres from January 2006 to June 2012 were analysed for patient, tumour and treatment-related prognostic factors. Patients receiving SRS/SRT were treated using Cyberknife. Variables were examined in univariate and multivariate testing. Results: Overall median survival was 3.4 months (95%CI: 1.7-5.1). Median survival for patients with multiple metastases receiving WBRT was 1.5 months, 1-3 metastases receiving WBRT was 3.6 months and 1-3 metastases receiving surgery or SRS/SRT was 8.9 months. ECOG score (${\leq}2$ vs >2, p=0.001), presence of seizure (yes versus no, p=0.031), treatment modality according to number of brain metastases (1-3 metastases+surgery or $SRS/SRT{\pm}WBRT$ vs 1-3 metastases+WBRT only vs multiple metastases+WBRT only, p=0.007) and the use of post-therapy systemic treatment (yes versus no, p=0.001) emerged as significant on univariate analysis. All four factors remained statistically significant on multivariate analysis. Conclusions: ECOG ${\leq}2$, presence of seizures, oligometastatic disease treated with aggressive local therapy (surgery or SRS/SRT) and the use of post-therapy systemic treatment are favourable prognostic factors in NSCLC patients with brain metastases.

사이버나이프의 품질관리 절차서 개발

장지선(Jisun Jang),이동한(Dong Han Lee),강영남(Young Nam Kang),신동오(Dong Oh Shin),김문찬(Moon Chan Kim),윤세철(Sei Chul Yoon),최일봉(Ihl Bohng Choi),김미숙(Mi Sook Kim),조철구(Chul Koo Cho),류성렬(Seong Yul Yoo),권수일(Soo Il Kwon) 대한방사선종양학회 2006 Radiation Oncology Journal Vol.24 No.3

목 적: 국내 실정에 적합한 사이버나이프의 표준화된 품질관리 절차서가 없어 이를 개발하고 유용성을 평가하고자 한다. 대상 및 방법: 사이버나이프의 구조적 특성과 치료 방법 등을 고려하여 품질관리 검사항목을 설정한 후, 적합한 시행 시기에 맞추어 주기적 분류를 하였다. 그리고 설정된 항목들은 각각의 품질관리 목적에 따라 일반적인 품질 관리(basic QC), 치료정확도 품질관리(delivery specific QC), 환자 맞춤형 품질관리(patient specific QC) 등 3개의 분 야로 구분하였다. 국내의 두 개 기관을 대상으로 개발된 품질관리 절차서의 각 항목을 비교하여 허용오차를 분석 하였다. 설정된 항목에 대한 허용 오차는 제작사에서 제공된 품질관리 자료와 현재 국내에 설치되어 있는 두 개 기관의 최근 3년간의 품질관리 수행 데이터 등을 근거하였으며, 각 항목에 대한 측정 결과를 토대로 품질관리 실 태를 분석하고 개발된 품질관리 절차서의 타당성을 검증하였다. 결 과: 개발된 사이버나이프 품질관리 절차서의 항목에 대하여 두 개 기관을 대상으로 정확성을 상호 비교 분석하였다. 모든 측정 결과는 사이버나이프의 품질관리 절차서에서 제시한 허용오차 범위 내에서 일치하고 있음을 확인하였다. 결 론: 본 연구에서 개발된 품질관리 절차서를 통해 사이버나이프에 대한 성능평가 기준을 확립할 수 있으며, 영상유도 정위방사선치료에 대한 정확성 및 안전성을 확보할 수 있을 것으로 생각된다. Purpose: Standardization quality assurance (QA) program of CyberKnife for suitable circumstances in Korea has not been established. In this research, we investigated the development of QA program for CyberKnife and evaluation of the feasibility under applications. Materials and Methods: Considering the feature of constitution for systems and the therapeutic methodology of CyberKnife, the list of quality control (QC) was established and divided dependent on the each period of operations. And then all these developed QC lists were categorized into three groups such as basic QC, delivery specific QC, and patient specific QC based on the each purpose of QA. In order to verify the validity of the established QA program, this QC lists was applied to two CyberKnife centers. The acceptable tolerance was based on the undertaking inspection list from the CyberKnife manufacturer and the QC results during last three years of two CyberKnife centers in Korea. The acquired measurement results were evaluated for the analysis of the current QA status and the verification of the propriety for the developed QA program. Results: The current QA status of two CyberKnife centers was evaluated from the accuracy of all measurements in relation with application of the established QA program. Each measurement result was verified having a good agreement within the acceptable tolerance limit of the developed QA program. Conclusion: It is considered that the developed QA program in this research could be established the standardization of QC methods for CyberKnife and confirmed the accuracy and stability for the image-guided stereotactic radiotherapy.

Stereotactic Radiosurgery with the CyberKnife for Pituitary Adenomas

Cho, Chul-Bum,Park, Hae-Kwan,Joo, Won-Il,Chough, Chung-Kee,Lee, Kyung-Jin,Rha, Hyoung-Kyun The Korean Neurosurgical Society 2009 Journal of Korean neurosurgical society Vol.45 No.3

Objective : In recent years, CyberKnife has emerged as an important treatment modality in the management of pituitary adenomas. Treatment results after performing CyberKnife and the complications of this procedure are reviewed. Methods : Twenty-six patients with pituitary adenomas received stereotactic radiosurgery with the CyberKnife (CKRS). The follow-up periods ranged from 7 months to 47 months (mean$\pm$SD : $30{\pm}12.7$ months). The patients consisted of 17 with non-functioning adenomas, 3 with prolactinomas and 6 with acromegaly. The change in the tumor volume, visual acuity, hormonal function, and complications by this therapy were analyzed in each case. Results : The tumor control rate was 92.3%. Hormonal function was improved in all of the 9 (100%) functioning adenomas. Hormonal normalization was observed in 4 of the 9 (44%) patients with a mean duration of 16 months. In two patients (7.6%), visual acuity worsened due to cystic enlargement of the tumor after CKRS. No other complications were observed. Conclusion : CyberKnife is considered safe and effective in selected patients with pituitary adenomas. However, longer follow-up is required for a more complete assessment of late toxicity and treatment efficacy.

삼차신경통에 대한 사이버나이프 방사선수술의 조기 치료 효과

문성권(Seong Kwon Mun),최병옥(Byung Ock Choi),최일봉(Ihl Bohng Choi),강영남(Young Nam Kang),장지선(Ji Sun Jang),강기문(Ki Mun Kang) 대한방사선종양학회 2006 Radiation Oncology Journal Vol.24 No.2

목 적: 삼차신경통 환자에서 사이버나이프 방사선수술이 효과적이며 안전한 치료방법인지 알아보고자 하였다. 대상 및 방법: 2004년 3월부터 2005년 5월까지 수술 후 실패하였거나 수술이 부적합한 삼차신경통 환자 26명을 대상으로 사이버나이프 방사선수술을 시행하여 후향적 분석을 하였다. 치료 표적은 삼차신경근 진입구역으로부터 3 mm 떨어진 지점의 삼차신경 최고 근위부를 제외한 6 mm 길이의 삼차신경 부위를 설정하고, 그 부위에 80% 등선량 곡선에 단일 조사로 총방사선량은 60∼64 Gy를 조사하였다(중앙선량: 64 Gy). 결 과: 추적관찰기간은 3∼15개월이었다(중앙추적관찰기간 : 9개월). 대상환자 26명에서 사이버나이프 방사선 수술 후 24시간 이내에 50% (13/26)에서 통증 완화를 관찰하였으며. 7일 이내에 조기 통증 완화를 보였던 환자는 96.2% (25/26)이었다. 치료 실패는 7.7% (2/26)에서 나타났으며 통증 개선 실패와 통증 재발이 각각 1명에서 관찰되었다. 치료 부작용으로 안면감각 감퇴가 11.5% (3/26)에서 관찰되었다. 결 론: 삼차신경통 환자를 대상으로 사이버나이프 방사선수술을 시행한 예비 결과로 비교적 안전하며, 효과적인 치료임을 확인하였다. Purpose: We evaluated whether Cyberknife radiosurgery is an effective and safe method of therapy for medically intractable trigeminal neuralgia (TN). Materials and Methods: We retrospectively analyzed the outcome of 26 patients, who failed to surgery or were not suitable candidates for invasive intervention and were treated by Cyberknife radiosurgery between March 2004 and May 2005. Radiosurgery doses of 60∼64 Gy were delivered to the 80% isodose line prescribed to an 6 mm length of the nerve, sparing the most proximal 3 mm away from the trigeminal nerve root entry zone (median dose: 64 Gy). Results: Follow-up period was 3∼15 months (median follow-up period: 9 months) Preliminary results from a cohort of 26 patients undergoing Cyberknife radiosurgery for TN showed that pain relief was achieved in 50% (13/26) of patients within the first 24 hrs after treatment. At last follow-up, 96.2% (25/26) of patients reported early pain relief within 7 days. Treatment failure developed in 2 of 26. Poor response occurred in one patient and relapse was observed in the other patient. 3 patients had hypoesthesia (11.5%), which was the only complication observed with any of our patients. Conclusion: With these results, authors assumed that Cyberknife radiosurgery for TN could be one of safe and effective therapeutic methods.

대장암의 간 전이에 대한 사이버나이프 치료 후 발생한 국소 식도 궤양 1예

정용우 ( Yong Woo Chung ),한동수 ( Dong Soo Han ),백창희 ( Chang Hee Paik ),김종표 ( Jong Pyo Kim ),최정혜 ( Jung Hye Choi ),손주현 ( Joo Hyun Sohn ),함준수 ( Joon Soo Hahm ) 대한소화기학회 2006 대한소화기학회지 Vol.47 No.6

사이버나이프는 정위 방사선 수술을 위하여 고안된 영상에 의해 유도되는 일종의 로봇 시스템이다. 사이버나이프는 초기에는 주로 두 개 내 양성 또는 악성 병소를 치료하기 위하여 개발되었으나 방사선 조사 때 틀이 필요없다는 이점으로 인해 최근에는 흉부와 복부의 종괴 치료에 도입되었다. 하지만 이에 대한 임상 경험은 아직까지 제한적이어서 이러한 치료에 의한 합병증 보고 또한 많지 않다. 저자들은 대장암의 간 전이에 대한 사이버나이프 치료 후 발생한 국소 식도궤양 1예를 경험하여 보고한다. CyberKnife is an image-guided robotic system designed for stereotactic radiosurgery. It uses the combination of robotics and image guidance to deliver concentrated and accurate beams of radiation to intracranial and extracranial targets. Although the frameless nature of the CyberKnife allows tumors in the chest and abdomen to be treated as well, complications associated with CyberKnife treatment have not been established yet due to its short clinical experience. We describe a case of Localized esophageal ulcerations after CyberKnife treatment for metastatic hepatic tumor of colon cancer. (Korean J Gastroenterol 2006;47:449-453)